Advanced Safety Management, 3rd Edition

ADDENDUM CMOC EXAMPLE 3

GAMMA CORPORATION

Pre-Task Analysis

Completed form must be submitted and work must be authorized before activity is commenced

Submitted by ____________________ Date _________ Location

Description of work

 

 

 

 

Commencement date _______________ Expected completion date

Permits, special skills and licenses: Work must not be commenced if required permits have not been received or if arrangements have not been made for the special skills and licenses required.

Permits	Required			Received
Confined space	____ Yes	____ No	____ Yes	____ No
Electrical	____ Yes	____ No	____ Yes	____ No
Combustion equipment	____ Yes	____ No	____ Yes	____ No
Excavation	____ Yes	____ No	____ Yes	____ No
Hot work	____ Yes	____ No	____ Yes	____ No
Lifting-rigging	____ Yes	____ No	____ Yes	____ No
Fire systems	____ Yes	____ No	____ Yes	____ No
Obtained
Will special skills be required	____ Yes	____ No	____ Yes	____ No
Will special licenses be needed	____ Yes	____ No	____ Yes	____ No

Check off each of the following that apply. Each checked subject is to be addressed in the pre-task planning.

___ Lockout/Tagout	___ Pinch points	___ Inadequate access	___ Hot/cold/burns
___ Chemical exposure/spill	___ Electrical shock	___ Sharp objects	___ Excavations
___ Equipment loading/unloading	___ Asbestos	___ Falling objects	___ Particles in eye
___ Elevated work	___ Fall from height	___ Manual lifting	___ Lighting
___ Lifting or rigging	___ Mobile equipment ...