AHA form.pdf

Activity Hazard Analysis (AHA) Activity/Work Task: Overall Risk Assessment Code (RAC) (Use highest code)

Project Location: Risk Assessment Code (RAC) Matrix Contract Number:

Severity Probability

Date Prepared: Frequent Likely Occasional Seldom Unlikely

Prepared by (Name/Title): Catastrophic E E H H M Critical E H H M L

Reviewed by (Name/Title): Marginal H M M L L Negligible M L L L L

Notes: (Field Notes, Review Comments, etc.) Step 1: Review each “Hazard” with identified safety “Controls” and determine RAC (See above)

“Probability” is the likelihood to cause an incident, near miss, or accident and identified as: Frequent, Likely, Occasional, Seldom or Unlikely. RAC Chart “Severity” is the outcome/degree if an incident, near miss, or accident did occur and identified as: Catastrophic, Critical, Marginal, or Negligible

E = Extremely High Risk H = High Risk

Step 2: Identify the RAC (Probability/Severity) as E, H, M, or L for each “Hazard” on AHA. Annotate the overall highest RAC at the top of AHA.

M = Moderate Risk L = Low Risk

Job Steps Hazards Controls RAC

Equipment to be Used Training Requirements/Competent or Qualified Personnel name(s) Inspection Requirements

Accepted By:____________________________ Date: ________________