HAZARD ASSESSMENT SURVEY DATA SHEET Example

DATE OF EVALUATION

DATE LAST EVALUATED

DEPARTMENT:

TELEPHONE:

ADDRESS/LOCATION:

NAME OF SECTION SUPERVISOR

Actions are required by:

NAME OF HAZARD COMMUNICATION PROGRAM MONITOR:

TOWN OF SUNFLOWER, PUBLIC WORKS DEPARTMENT

POTENTIAL HAZARDS
Water Sampling/Acid Preservation:

Exposure to corrosive materials can cause several types of injuries, both acute and chronic. Primary injuries include

ADD ACID TO WATER

EVALUATION
To Date:

SPILL RESPONSE and CLEAN UP PROCEDURES:

1 of 2 pages

CONTROLS

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Existing Controls:
PPE:
Engineering:
Administrative:

2 of 2 pages
Surveyed By:

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DATE OF EVALUATION
DEPARTMENT:

HAZARD ASSESSMENT SURVEY DATA SHEET

DATE LAST EVALUATED

TOWN OF SUNFLOWER, PUBLIC WORKS DEPARTMENT

TELEPHONE:

ADDRESS/LOCATION:

NAME OF SECTION SUPERVISOR

Actions are required by:

NAME OF HAZARD COMMUNICATION PROGRAM MONITOR:

POTENTIAL HAZARDS

CHAINSAW

EVALUATION

CONTROLS

Existing:

Recommended: More safety instruction classes and annual refresher tool safety videos.

Outsourcing major tree trimming to independent contactor.

Surveyed By:

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HAZARD ASSESSMENT SURVEY DATA SHEET Example

DATE OF EVALUATION
DEPARTMENT:

DATE LAST EVALUATED

TOWN OF SUNFLOWER, PUBLIC WORKS DEPARTMENT

TELEPHONE:

ADDRESS/LOCATION:

NAME OF SECTION SUPERVISOR

Actions are required by:

NAME OF HAZARD COMMUNICATION PROGRAM MONITOR:

POTENTIAL HAZARDS

TRAFFIC / BARRICADING

EVALUATION

CONTROLS

Existing:

Recommended:
Surveyed By:

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Reviewed By:

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DATE OF EVALUATION
DEPARTMENT:

FIRE EVACUATION PLAN Example

DATE LAST EVALUATED

TOWN OF SUNFLOWER, PUBLIC WORKS DEPARTMENT

TELEPHONE:

ADDRESS/LOCATION:
Actions are required by:

NAME OF DEPARTMENT SUPERINTENDENT:

NAME OF HAZARD COMMUNICATION PROGRAM MONITOR:
POTENTIAL HAZARDS

FIRE:

911
IF SAFE TO DO SO!

CONTROLS

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DATE OF EVALUATION
DEPARTMENT:

FIRE EVACUATION/EGRESS PLAN

DATE LAST EVALUATED

DEPARTMENT:

TELEPHONE:

ADDRESS/LOCATION:
Actions are required by:

NAME OF DEPARTMENT DIRECTOR:

NAME OF HAZARD COMMUNICATION PROGRAM MONITOR:

FIRE

CONTROLS

Surveyed By:

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HAZARDOUS MATERIALS INVENTORY FORM

DATE:

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LOCATION:

DEPARTMENT:SECTION:

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Common Hazard Communication Acronyms

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THRESHOLD LIMIT VALUES (TLV's)

1. TLV-TWA
2. TLV-STEL
3. TLV-C

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