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Safety Blitz Form

Job Hazard Analysis Focus:

Hand Safety & Laceration Prevention

Date:

Month

Day

Year

Job #:

Job Site:(Required)

Time:

Hours

:

Minutes

AM/PM

Completed By (Competent Person)

Project Manager(Required)

1. Job Description

(Required)

2. Required PPE Checklist

Gloves: Well-fitting, puncture- or cut-proof

Y

N

N/A

Chemical PPE: Appropriate gloves for hazardous substances

Y

N

N/A

Face Shield / Safety Glasses / Goggles

Y

N

N/A

Hard Hat

Y

N

N/A

Steel Toe Boots

Y

N

N/A

3. Hazard Identification & Safety Checklist

Safety Question

Are hands/fingers clear of pinch and crush points?

Status (Y/N/NA)

Corrective Actions

Are proper guards in place on all power tools?

Status (Y/N/NA)

Corrective Actions

Are objects being cut/worked on secured from movement?

Status (Y/N/NA)

Corrective Actions

Is the area free of sharp, spiked, or jagged edges?

Status (Y/N/NA)

Corrective Actions

Are gloves sized correctly (not too large)?

Status (Y/N/NA)

Corrective Actions

Is a neutralization solution ready for chemical contact?

Status (Y/N/NA)

Corrective Actions

4. Control Measures & Additional Info

5. Management & Competent Person Verification

Training: Workers trained on specific hand safety.

Equipment: Tools maintained and guards in working order.

6. Sign-Off

Operator:

Date:

MM slash DD slash YYYY

Competent Person:

Date:

MM slash DD slash YYYY

Send Form to Client?(Required)

Yes

No

Client Name

First Last

Client Email

Δ