ࡱ> gif +bjbj++ q^AA""$ $ $PhD\%R0$T 4  $$$$$$$,&`)n% %" %"""   $" $""r#$G|Ӧz!*{$$,%0\%$)")$"$( %%" \%) $ :   Please retain this form within the department/section when completed. To be completed by staff trained in manual handling techniques on return to their workplace This checklist will help identify hazards and enable subsequent Risk Assessments to be completed where hazards cannot be eliminated. [See Section 19.1 - 19.5]. Room/Location: __________________________ Name of Person: ____________________________________ Position: ________________________________ Nature of Work: _________________________________ _______________________________________________________________________________________ 1. NATURE OF THE MANUAL HANDLING WITH WHICH YOU ARE INVOLVED: [Please tick] Lifting  FORMCHECKBOX  Putting down  FORMCHECKBOX  Carrying  FORMCHECKBOX  Pushing  FORMCHECKBOX  Pulling  FORMCHECKBOX  Manual Handling Frequency: Habitual  FORMCHECKBOX  Significant  FORMCHECKBOX  Occasional FORMCHECKBOX  2. CHARACTERISTICS OF THE LOAD: [Please tick] (a) Object(s) size (Largest Single Dimension) Large (75cm+)  FORMCHECKBOX  Medium (30-75cm)  FORMCHECKBOX  Small (30cm)  FORMCHECKBOX  Awkward (Two or more dimensions exceeding 75cm)  FORMCHECKBOX  (b) Object(s) shape Regular  FORMCHECKBOX  Irregular  FORMCHECKBOX  Compact FORMCHECKBOX  Unwieldy FORMCHECKBOX  Awkward  FORMCHECKBOX  (c) Object Strength/Packaging Rigid  FORMCHECKBOX  Flexible  FORMCHECKBOX  Soft  FORMCHECKBOX  Easy to grasp  FORMCHECKBOX  Difficult to grasp  FORMCHECKBOX  Strongly secured  FORMCHECKBOX  Poorly secured  FORMCHECKBOX  Liable to break  FORMCHECKBOX  Liable to open  FORMCHECKBOX  (d) Object(s) surface texture & temperature Smooth  FORMCHECKBOX  Rough  FORMCHECKBOX  Clean  FORMCHECKBOX  Dirty  FORMCHECKBOX  Oily  FORMCHECKBOX  Greasy  FORMCHECKBOX  Very Hot  FORMCHECKBOX  Hot  FORMCHECKBOX  Warm  FORMCHECKBOX  Cold  FORMCHECKBOX  Very cold  FORMCHECKBOX  (e) Contents of objects Firmly packed  FORMCHECKBOX  Loosely packed  FORMCHECKBOX  Likely to shift  FORMCHECKBOX  Solid  FORMCHECKBOX  Liquid  FORMCHECKBOX  (f) Load Mass (Typical weights of loads) Typical Frequencies per hour/day Mass of object(s) Lifting Put down Pushing Pulling Overall 0 - 5 kg 6 - 10 kg 11 - 15 kg 16 - 20 kg 21 - 25 kg 26 - 30 kg 31 - 50 kg 51+ kg (g) Assistance/Mechanical Equipment Is assistance or mechanical equipment available for use with heavy/awkward loads? Yes/No If No, please comment: _______________________________________________________________ ________________________________________________________________________________ 3. CHARACTERISTICS OF THE MOVEMENT/ACTIVITY (a) Height of Manual Lift (With use of portable steps or stepladders) LOAD PICK-UP/DROP-OFF CODES Load Pick up point codes Load Drop point codes A. Floor Level 1. Floor Level B. Knee Height 2. Knee Height C. Knuckle Height 3. Knuckle Height D. Elbow Height 4. Elbow Height E. Shoulder Height 5. Shoulder Height F. Head Height 6. Head Height G. Overhead Height 7. Overhead Height Load weight Typical Start & End points (using above codes e.g. A-3, B-1, F-7 etc). 0 - 5kg ________________________________________________________ 6 - 10kg ________________________________________________________ 11 - 15kg ________________________________________________________ 16 - 20kg ________________________________________________________ 21 - 25kg ________________________________________________________ 26 - 30kg ________________________________________________________ 31 - 50kg ________________________________________________________ 51+kg ________________________________________________________ NOTE: Please use an asterisk (**) to indicate where step ladders/portable steps are used e.g. A-3** (b) Position of Load and Body Are the objects held (unsupported) at distance from the body?  FORMCHECKBOX  Arms at full extension  FORMCHECKBOX  Object wt(s)___________________ Arms at mid extension  FORMCHECKBOX  Object wt(s)___________________ Are the objects held close to the body?  FORMCHECKBOX  Object wt(s)___________ (c) Upper Body Rotation Does movement of the objects (load) involve twisting of the torso, with the lower body in a stationary position Y/N If `Yes', does the movement involve twisting of: the upper spine  FORMCHECKBOX  the lower spine  FORMCHECKBOX  (d) Posture Is movement of the object(s) undertaken with the body in: a stable position  FORMCHECKBOX  an unstable position  FORMCHECKBOX  If `unstable', please describe: __________________________________________________________________ __________________________________________________________________________________________ Can all movements of the object(s) be undertaken safely using the manual handling techniques demonstrated Y/N If `No', please comment: _______________________________________________________________________ _____________________________________________________________________________________ (e) Is the carrying distance: Short  FORMCHECKBOX  Moderate  FORMCHECKBOX  Long  FORMCHECKBOX  If long, are rest periods included? Y/N CHARACTERISTICS OF THE WORKING ENVIRONMENT (with respect to Manual Handling only!) (a) Terrain Indoor  FORMCHECKBOX  Outdoor  FORMCHECKBOX  Path/road Green area  FORMCHECKBOX  Level Sloping Steps  FORMCHECKBOX  Stairs  FORMCHECKBOX  Firm  FORMCHECKBOX  Soft  FORMCHECKBOX  Yielding  FORMCHECKBOX  (b) Surface (under foot) Wet  FORMCHECKBOX  Dry  FORMCHECKBOX  Polished  FORMCHECKBOX  Smooth  FORMCHECKBOX  Raised surfaces  FORMCHECKBOX  (c) Access & Egress Good access  FORMCHECKBOX  Restricted access  FORMCHECKBOX  Poor access  FORMCHECKBOX  Free of trip hazards  FORMCHECKBOX  not free of trip hazards  FORMCHECKBOX  Comment:________________________________________________________________________________________ 4. CHARACTERISTICS OF THE WORKING ENVIRONMENT (Cont.) (d) Housekeeping: Tidy  FORMCHECKBOX  Untidy  FORMCHECKBOX  (e) Lay out of furniture/equipment: Very good  FORMCHECKBOX  Good  FORMCHECKBOX  Poor  FORMCHECKBOX  (f) Seating: Very good  FORMCHECKBOX  Good  FORMCHECKBOX  Fair  FORMCHECKBOX  Poor  FORMCHECKBOX  (g) Lighting: Very good  FORMCHECKBOX  Good  FORMCHECKBOX  Poor  FORMCHECKBOX  (h) General Does the work place/environment facilitate the safe handling and movement of loads safely? Y/N (If `No', please detail): ________________________________________________________________________ _____________________________________________________________________________ Can you modify the work environment and your method to allow proper manual handling techniques to be used? Y/N 5. INDIVIDUAL CHARACTERISTICS (a) Age 17-20  FORMCHECKBOX  21 - 30  FORMCHECKBOX  31 - 40  FORMCHECKBOX  41 - 50  FORMCHECKBOX  50+  FORMCHECKBOX  (b) Can you alter your rate of lifting, pushing, pulling? Y/N (c) Did you ever have a back injury before or do you have a history of back pain? Y/N If `Yes' please detail: ________________________________________________________________________________________________________________________________________________________________ (d) Do you have a medical or physical condition that would impact on you lifting, pushing or pulling loads? Y/N If `Yes' please describe: ____________________________________________________________________________________________ (e) Does your normal clothing allow you to adopt suitable lifting techniques & postures? Y/N 6. GENERAL INFORMATION (a) When did you complete your Manual Handling Course - Date:_____________ am /pm____________ (b) Are you now aware of the dangers of incorrect manual handling? Y/N (c) Do you understand the correct techniques that are required to work safely and prevent injury to yourself? Y/N (d) Was the Manual Handling Training received relevant to your work? Y/N (e) Will you be able to implement the manual handling techniques shown? Y/N If `No' Please explain why: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Signed by: ____________________________________ Assessment Date: _________________   DEPARTMENT SAFETY STATEMENT DOCUMENT NO.3: Hazard Identification and Risk Assessment SECTION 19.3.3.1 - Manual Handling Self Assessment checklist Rev.2 Date: Nov 99 PAGE  PAGE 1 of  NUMPAGES 3 Common\Doc 3\Sect19.3.3-1 DOCUMENT NO.3: Hazard Identification and Risk Assessment SECTION 19.3.3.1 - Manual Handling Self Assessment checklist (Cont.) 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