Activity Hazard Analysis (AHA)
Revision 0
Date:
Rev.
0 – 5 = Low Risk
Job Name:
RISK ASSESSMENT RATING (RAR)
6 – 10 = Moderate Risk
11 – 15 = High Risk
Job Number:
Severity of Potential Consequences
16 – 25 = Unacceptable Risk
Likelihood of
Occurrence
Location:
Activity:
Rare – 1
Unlikely – 2
Occasional – 3
Likely – 4
Almost Certain – 5
Insignificant – 1
Minor – 2
Moderate – 3
Major – 4
1
2
3
4
5
2
4
6
8
10
3
6
9
12
15
4
8
12
16
20
Company Name:
Superintendent:
Project Manager:
Foreman:
Safety Manager:
Competent Person:
Catastrophic –
5
5
10
15
20
25
Additional PPE Requirements
PPE
Tasks/Activity
NO / YES
PPE
NO / YES
Potential Hazards
PPE
NO / YES
Actions to Eliminate or Minimize Hazards
AHA Page 1
Activity Hazard Analysis (AHA)
Revision 0
Tasks/Activity
Potential Hazards
Actions to Eliminate or Minimize Hazards
AHA Page 2
Activity Hazard Analysis (AHA)
Revision 0
AHA Signature Page
A signature means that the worker has read, understands, and will comply with this AHA, including taking actions to
eliminate or minimize general hazards on the ____________ worksite
Company:
Name(Last, First, MI):
Signature:
AHA Signature Page ____
Date (dd:mm:yyyy):