Pre-Work Hazard Analysis Form



MFD File Number Job Title/Description

Job Location Briefing Date

MFD Supervisor Phone Pager

List all crew members:

Job Step Hazard Control

What tasks might you perform? Have you considered?

θ Working at heights or elevated surfaces θ Fall protection?

θ Ladder safety?

θ Entering/ working in accelerator housing θ Work Authorization Plan?

θ Radiation Worker Training level?

θ Remove items from accelerator housing θ OHP survey?

θ Welding, soldering, torch cutting or use open flame θ Hot work permit?

θ Radiation Work Permit?

θ Entering a confined space θ Confined space permit?

θ Machining, grinding, drilling, cutting θ Radiation Work Permit?

θ Penetration Permit?

θ Call Industrial Hygienist?

θ Working with lead or other hazardous materials θ Call Industrial Hygienist?

θ Lifting heavy or awkward objects θ H&R lift plan?

θ Certified equipment and gear?

θ Energized electrical work activity (>50 volts or 10 joules) θ Electrical Work Plan?

θ Control hazardous energy θ Lock Out Tag Out?

(Electrical, mechanical, hydraulic, pneumatic, thermal, chemical) θ Equipment Lockout Procedure?

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