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					                          Activity Hazard Analysis
     Contract Number:                    Project Title/Location:
   Definable Feature of                    QC Plan Reference:
                Work:
        Date Prepared:                    Estimated Start Work
                                                          Date:
Prime Contractor Name:                  Project Safety Manager
                                                         Name:
          Prepared By:                                    Title:
         Approved By:                                     Title:
   Competent/Qualified                                    Title:
    Person Required for
              Activity:

 Equipment to be Used:                 Inspection Requirements:
Training Requirements:




                                                                   Form Rev: Orig
                                                   Acceptance
Accepted By:                                                Title:                           Date:
   Overall Risk Assessment:
                                     Code          Authority
                                       E           Commander
               Responsibility:
                                       H           Resident Engineer
                                     M or L        QAR
                                             Risk Decision Matrix
                                                                Probability Levels
                                              Frequent     Likely    Occasional         Remote           Unlikely
                               Probability       A           B            C               D                 E
                                 Criteria:
                                              Risk Levels:
                                              Extremely High: Loss of ability to complete contract
                                              High: Significantly impacts ability to complete contract
                                 Severity     Medium: Impacts ability to complete contract
      Severity Criteria           Code        Low: Little or no impact to contract
Catastrophic - Death or             I
permanent total disability,
System Destruction, major
property damage
Critical - Permanent partial        II
disability, temporary total
disability, major system
damage or significant
property damage
Moderate - Temporary               III
disabling injury, lost
workday case, minor
property damage
                                                                                                   Form Rev: Orig
  Basic Job Steps                                         Recommended Controls to
                        Potential Safety/Health Hazards
(Principal Job Steps)                                        Eliminate Hazards




                                                                       Form Rev: Orig

				
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posted:8/1/2012
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