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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