Form 1112-5 UNITED STATES DEPARTMENT OF THE INTERIOR Revised for AFS BUREAU OF LAND MANAGEMENT (MARCH 2013) RISK MANAGEMENT WORKSHEET

1. 2. Page _1___of ____5 Organizatio 3. 4. 5. Ending 6. Date Prepared: Operation / Beginning Date: MARCH 11, 2013 Task Date:

7. Prepared by (Name / Duty Position) BRANDON POE / DUTY OFFICER

8. 9. Assess the 10. Control 11. Assess 12. How to 13. Supervisors and Evaluation by: (Continuous Leader Checks, Buddy System, etc.) Identified Hazards: Measures the Hazards: Implement the Hazards Initial Risk Developed for Residual Risk Controls: Identified (May Be (Be N HazardsM: M Filled inS By C (Be N M M S C (Be (Be Specific) Specific) Specific) Specific) SUMMARY OF X SUMMARY OF X ALL GEAR SUPERVISORY HAZARDS NECESSARY MUST BE RESPONSIBILI BOATING PPE/GEAR: ACQUIRED TY OPERATION IN AND ALL REMOTE TRAINING ALASKAN - APP ACCOMPLISH WATERS RO ED PRIOR TO PRI TRIP. - FAL ATE CO L AST OVE GU RB ARD OA APP RD RO - HYP VED OTH PFD ER COL MIA - D - DR WA OW TER NIN PPE G OF WE - SW T/D EPT RY AW SUI AY TS - SW - FIEL AM D PIN FIR G/SI ST NKI AID NG KIT BAD - - OA WE RS ATH OR ER PAD - LOS DLE T/S S TRA EM NDE - D ER GE *DETAILS ON NCY THE FLA FOLLOWING RES PAGES OR SIG NAL S - SUR VIV AL KIT S WIT H EXT RA FO OD, 2 14. NEGLIGIBLE MODERATE SERIOUS CRITICAL Remaining (AFS Manager/Associate (State Risk Level (Task Leader) (Branch Chief) Manager) Director/Associate) After X 15. RISK DECISION AUTHORITY: (Approval/Authority Signature Block) (If Initial Risk Level is CRITICAL, SERIOUS or MODERATE: Brief Risk Decision Authority at that level on Controls and Control Measures used to reduce risks) (Note: if the person preparing the form signs this block, the signature indicates only that the appropriate risk decision authority was notified of the initial risk level, control measures taken and appropriate resources requested; and that the risk was accepted by the decision authority.)

______Printed Name / Signature CONTINUED 8. Identified 9. Assess 10. Control 11. Assess 12. How to 13. Supervisors and Evaluation by: (Continuous Leader Checks, Buddy System, etc.) Hazards the Measures the Hazards: Implement Hazards: Developed Residual Risk the Controls: Initial Risk for Identified (May Be Hazards: Filled in By (Be N M M S C (Be N M M S C (Be (Be FALLSpecific) X Specific) X Specific) Specific) OVERBOARD: - PE - BL - CR DROWNING RS M EW ON WIL CHI AL L EF/ FL PU SU OA RC PE TAT HA RVI ION SE SO DE AN R VIC D RE E SU SP (PF PPL ON D) Y SIBI AP ALL LIT PR AP Y OP PR TO RIA OP EN TE RIA SU TO TE RE SIZ BO ALL E ATI TR OF NG AIN CR PP ING AFT E AN , RE D TY QUI PP PE RE E IS OF D PR WA FO OVI TE R DE R TH D AN E TO D TRI EM PE P PL RS OY ON - SWI EE 3 14. NEGLIGIBLE MODERATE SERIOUS CRITICAL Remaining (AFS Manager/Associate (State Risk Level (Task Leader) (Branch Chief) Manager) Director/Associate) After X 15. RISK DECISION AUTHORITY: (Approval/Authority Signature Block) (If Initial Risk Level is CRITICAL, SERIOUS or MODERATE: Brief Risk Decision Authority at that level on Controls and Control Measures used to reduce risks) (Note: if the person preparing the form signs this block, the signature indicates only that the appropriate risk decision authority was notified of the initial risk level, control measures taken and appropriate resources requested; and that the risk was accepted by the decision authority.)

______Printed Name / Signature CONTINUED NE FT S LS WA OP SIZ TE ER E R ATI TH RE NG AT SC ON WIL UE WA L TE TE BE CH RC WO I RA RN FT AT ALL - BO TIM AT ES OP WH ER EN AT ON OR TH IS E IN WA CH TE AR R GE CR WH AFT EN ON - NE TH VE E R WA WE TE AR R LO OS - BU E DD FIT Y TIN SY G ST WA EM DE OF RS LO OR OK HIP OU BO TS OT AN S D TH AC 4 14. NEGLIGIBLE MODERATE SERIOUS CRITICAL Remaining (AFS Manager/Associate (State Risk Level (Task Leader) (Branch Chief) Manager) Director/Associate) After X 15. RISK DECISION AUTHORITY: (Approval/Authority Signature Block) (If Initial Risk Level is CRITICAL, SERIOUS or MODERATE: Brief Risk Decision Authority at that level on Controls and Control Measures used to reduce risks) (Note: if the person preparing the form signs this block, the signature indicates only that the appropriate risk decision authority was notified of the initial risk level, control measures taken and appropriate resources requested; and that the risk was accepted by the decision authority.)

______Printed Name / Signature CONTINUED AT TIV WIL E L AS FIL SIS L TA WIT NC H E WA BY TE PA R SS IN EN FA GE ST RS MO VIN G OR PO WE RF UL WA TE R. WE AR ON LY TIG HT FIT TIN G NE OP RE NE WA DE RS - AL WA YS 5 14. NEGLIGIBLE MODERATE SERIOUS CRITICAL Remaining (AFS Manager/Associate (State Risk Level (Task Leader) (Branch Chief) Manager) Director/Associate) After X 15. RISK DECISION AUTHORITY: (Approval/Authority Signature Block) (If Initial Risk Level is CRITICAL, SERIOUS or MODERATE: Brief Risk Decision Authority at that level on Controls and Control Measures used to reduce risks) (Note: if the person preparing the form signs this block, the signature indicates only that the appropriate risk decision authority was notified of the initial risk level, control measures taken and appropriate resources requested; and that the risk was accepted by the decision authority.)

______Printed Name / Signature CONTINUED CA RR Y AT LEA ST ON E TH RO W RO PE ON BO AR D EA CH CR AFT FALL X X *SAME AS OVERBOARD: - WE - PR ABOVE* SWEPT AWAY AR E- BY FAST PF TRI MOVING D P WATER: AP PLA PR NNI - CO OP NG, LISI RIA MA ON TE P OF TO ST BO CL UD DY AS Y, WIT S ME H OF ETI OB WA NG JEC TE WIT TS R H IN BEI PE TH NG OP E TR LE WA AV EX TE ELE PE R D RIE 6 14. NEGLIGIBLE MODERATE SERIOUS CRITICAL Remaining (AFS Manager/Associate (State Risk Level (Task Leader) (Branch Chief) Manager) Director/Associate) After X 15. RISK DECISION AUTHORITY: (Approval/Authority Signature Block) (If Initial Risk Level is CRITICAL, SERIOUS or MODERATE: Brief Risk Decision Authority at that level on Controls and Control Measures used to reduce risks) (Note: if the person preparing the form signs this block, the signature indicates only that the appropriate risk decision authority was notified of the initial risk level, control measures taken and appropriate resources requested; and that the risk was accepted by the decision authority.)

______Printed Name / Signature CONTINUED NC - TR - ST ED AP AY IN PE ON TH D BA AT BY CK, TY SW KE PE EE EP OF PE FE WA RS ET TE OR POI R SN NT AG ED - PU S DO RC WN HA ST SE RE PR AM, OP HE ER AD GE POI AR NT FO ED R UP TH ST E RE CL AM AS S - AV OF OID WA VISI TE BLE R SW EE - ATT PE EN RS D IF SWI PO FT SSI WA BLE TE R - TU RE RN SC BO UE 7 14. NEGLIGIBLE MODERATE SERIOUS CRITICAL Remaining (AFS Manager/Associate (State Risk Level (Task Leader) (Branch Chief) Manager) Director/Associate) After X 15. RISK DECISION AUTHORITY: (Approval/Authority Signature Block) (If Initial Risk Level is CRITICAL, SERIOUS or MODERATE: Brief Risk Decision Authority at that level on Controls and Control Measures used to reduce risks) (Note: if the person preparing the form signs this block, the signature indicates only that the appropriate risk decision authority was notified of the initial risk level, control measures taken and appropriate resources requested; and that the risk was accepted by the decision authority.)

______Printed Name / Signature CONTINUED DY AN ON D TO SU FR RVI ON VAL T, TR HE AIN AD ING FO BE RW FO AR RE D TR AN AV D ELI DO NG WN ON ST FA RE ST AM MO AN VIN D G ST WA RO TE NG R LY SWI M OV ER TO P OF UN AV OID ABL E OB ST AC LES

8 14. NEGLIGIBLE MODERATE SERIOUS CRITICAL Remaining (AFS Manager/Associate (State Risk Level (Task Leader) (Branch Chief) Manager) Director/Associate) After X 15. RISK DECISION AUTHORITY: (Approval/Authority Signature Block) (If Initial Risk Level is CRITICAL, SERIOUS or MODERATE: Brief Risk Decision Authority at that level on Controls and Control Measures used to reduce risks) (Note: if the person preparing the form signs this block, the signature indicates only that the appropriate risk decision authority was notified of the initial risk level, control measures taken and appropriate resources requested; and that the risk was accepted by the decision authority.)

______Printed Name / Signature CONTINUED FALL X X *SAME AS OVERBOARD: - BO - ALL ABOVE* HYPOTHERMI AT FIE A FROM OP LD SUBMERSION ER WO IN VERY COLD AT RK WATER OR’ ER S S SE IN ATI RE NG MO INS TE TR AR UC EA TIO S NS MU WIL ST L ATT AL EN HYPOTHERMI WA D A CONTINUED YS FIR BE ST FO AID LLO AN WE D D CP R - RE TR MAI AIN N ING SE AN AT D ED/ ALL LO RE W QUI IN RE TH D E RE BO FR AT ES AT HE ALL R TIM TR ES AIN 9 14. NEGLIGIBLE MODERATE SERIOUS CRITICAL Remaining (AFS Manager/Associate (State Risk Level (Task Leader) (Branch Chief) Manager) Director/Associate) After X 15. RISK DECISION AUTHORITY: (Approval/Authority Signature Block) (If Initial Risk Level is CRITICAL, SERIOUS or MODERATE: Brief Risk Decision Authority at that level on Controls and Control Measures used to reduce risks) (Note: if the person preparing the form signs this block, the signature indicates only that the appropriate risk decision authority was notified of the initial risk level, control measures taken and appropriate resources requested; and that the risk was accepted by the decision authority.)

______Printed Name / Signature CONTINUED WH ING EN BO - SWI AT FT IS WA IN TE MO R TIO RE N SC (OP UE ER TE AT CH OR I MA Y HA VE TO ST AN D FO R CL EA R VIE W) - IF AC TIN G AS BO W LO OK OU T RE MAI N AS LO W 10 14. NEGLIGIBLE MODERATE SERIOUS CRITICAL Remaining (AFS Manager/Associate (State Risk Level (Task Leader) (Branch Chief) Manager) Director/Associate) After X 15. RISK DECISION AUTHORITY: (Approval/Authority Signature Block) (If Initial Risk Level is CRITICAL, SERIOUS or MODERATE: Brief Risk Decision Authority at that level on Controls and Control Measures used to reduce risks) (Note: if the person preparing the form signs this block, the signature indicates only that the appropriate risk decision authority was notified of the initial risk level, control measures taken and appropriate resources requested; and that the risk was accepted by the decision authority.)

______Printed Name / Signature CONTINUED AS PO SSI BLE IN TH E BO AT - CA RR Y SU RVI VAL KIT ON TH E BO AT IN A WA TE RP RO OF BA G CO NT AIN ING AN EX TR A SE T OF CL OT 11 14. NEGLIGIBLE MODERATE SERIOUS CRITICAL Remaining (AFS Manager/Associate (State Risk Level (Task Leader) (Branch Chief) Manager) Director/Associate) After X 15. RISK DECISION AUTHORITY: (Approval/Authority Signature Block) (If Initial Risk Level is CRITICAL, SERIOUS or MODERATE: Brief Risk Decision Authority at that level on Controls and Control Measures used to reduce risks) (Note: if the person preparing the form signs this block, the signature indicates only that the appropriate risk decision authority was notified of the initial risk level, control measures taken and appropriate resources requested; and that the risk was accepted by the decision authority.)

______Printed Name / Signature CONTINUED HIN G AN D FIR E ST AR TIN G MA TE RIA LS - CA RR Y SM ALL SU RVI VAL KIT WIT H ST AR TE R AN D IN TH E PO CK ET S OF YO UR PF D OR ON 12 14. NEGLIGIBLE MODERATE SERIOUS CRITICAL Remaining (AFS Manager/Associate (State Risk Level (Task Leader) (Branch Chief) Manager) Director/Associate) After X 15. RISK DECISION AUTHORITY: (Approval/Authority Signature Block) (If Initial Risk Level is CRITICAL, SERIOUS or MODERATE: Brief Risk Decision Authority at that level on Controls and Control Measures used to reduce risks) (Note: if the person preparing the form signs this block, the signature indicates only that the appropriate risk decision authority was notified of the initial risk level, control measures taken and appropriate resources requested; and that the risk was accepted by the decision authority.)

______Printed Name / Signature CONTINUED YO UR PE RS ON - KN OW SIG NS AN D TR EA TM EN T OF HY PO TH ER MIA - LEA RN SEL F RE SC UE “HE AT HU DD LE” BO DY HE AT RE TE NTI ON 13 14. NEGLIGIBLE MODERATE SERIOUS CRITICAL Remaining (AFS Manager/Associate (State Risk Level (Task Leader) (Branch Chief) Manager) Director/Associate) After X 15. RISK DECISION AUTHORITY: (Approval/Authority Signature Block) (If Initial Risk Level is CRITICAL, SERIOUS or MODERATE: Brief Risk Decision Authority at that level on Controls and Control Measures used to reduce risks) (Note: if the person preparing the form signs this block, the signature indicates only that the appropriate risk decision authority was notified of the initial risk level, control measures taken and appropriate resources requested; and that the risk was accepted by the decision authority.)

______Printed Name / Signature CONTINUED TE CH NIQ UE S - WE AR PF D PR OVI DIN G GR EA TE R INS UL ATI ON AN D BO DY CO VE RA GE SU CH AS FL OA T CO AT S, WE T SUI TS, DR Y SUI 14 14. NEGLIGIBLE MODERATE SERIOUS CRITICAL Remaining (AFS Manager/Associate (State Risk Level (Task Leader) (Branch Chief) Manager) Director/Associate) After X 15. RISK DECISION AUTHORITY: (Approval/Authority Signature Block) (If Initial Risk Level is CRITICAL, SERIOUS or MODERATE: Brief Risk Decision Authority at that level on Controls and Control Measures used to reduce risks) (Note: if the person preparing the form signs this block, the signature indicates only that the appropriate risk decision authority was notified of the initial risk level, control measures taken and appropriate resources requested; and that the risk was accepted by the decision authority.)

______Printed Name / Signature CONTINUED TS OR TY PE III/V AN TI EX PO SU RE CO VE RA LLS COLLISION X X *SAME AS WITH OBJECT - AV - PR ABOVE* IN WATER, OID E- OVERTURNED AN TRI BOAT CE P BY PLA ADJ NNI US NG, TIN CR G EW SP ME EE ETI D NG AN S, - CO D RE NT PO VIE AC SITI W T ON AN INJ OF D UR CR INV Y AFT EN FR TO TO OM WA RY BEI TE OF NG R SU TH CO PPL RO NDI IES WN TIO FR NS - DAI 15 14. NEGLIGIBLE MODERATE SERIOUS CRITICAL Remaining (AFS Manager/Associate (State Risk Level (Task Leader) (Branch Chief) Manager) Director/Associate) After X 15. RISK DECISION AUTHORITY: (Approval/Authority Signature Block) (If Initial Risk Level is CRITICAL, SERIOUS or MODERATE: Brief Risk Decision Authority at that level on Controls and Control Measures used to reduce risks) (Note: if the person preparing the form signs this block, the signature indicates only that the appropriate risk decision authority was notified of the initial risk level, control measures taken and appropriate resources requested; and that the risk was accepted by the decision authority.)

______Printed Name / Signature CONTINUED OM AN LY BO D PR AT DE E- GR TRI EE P OF BRI DE EFI BRI NG S S - DR PR OW ES - ALL NIN EN FIE G T LS WO - AV RK OID ER AN S CE IN BY RE PO MO STI TE NG AR A EA LO S OK MU OU ST T ATT AT EN BO D W FIR ST - AV AID OID AN AN D CE CP BY R NO TR T AIN EX ING CE AN EDI D NG ALL PA RE SS QUI EN RE GE D 16 14. NEGLIGIBLE MODERATE SERIOUS CRITICAL Remaining (AFS Manager/Associate (State Risk Level (Task Leader) (Branch Chief) Manager) Director/Associate) After X 15. RISK DECISION AUTHORITY: (Approval/Authority Signature Block) (If Initial Risk Level is CRITICAL, SERIOUS or MODERATE: Brief Risk Decision Authority at that level on Controls and Control Measures used to reduce risks) (Note: if the person preparing the form signs this block, the signature indicates only that the appropriate risk decision authority was notified of the initial risk level, control measures taken and appropriate resources requested; and that the risk was accepted by the decision authority.)

______Printed Name / Signature CONTINUED R/ RE WEI FR GH ES T HE LO R ADI TR NG AIN PO ING ST ED - SWI ON FT BO WA AT’ TE S R DA RE TA SC PLA UE TE TE CH I - RE MAI N PO SITI ON ED LO W IN BO AT WH EN EV ER PO SSI BLE

- IF OV ER 17 14. NEGLIGIBLE MODERATE SERIOUS CRITICAL Remaining (AFS Manager/Associate (State Risk Level (Task Leader) (Branch Chief) Manager) Director/Associate) After X 15. RISK DECISION AUTHORITY: (Approval/Authority Signature Block) (If Initial Risk Level is CRITICAL, SERIOUS or MODERATE: Brief Risk Decision Authority at that level on Controls and Control Measures used to reduce risks) (Note: if the person preparing the form signs this block, the signature indicates only that the appropriate risk decision authority was notified of the initial risk level, control measures taken and appropriate resources requested; and that the risk was accepted by the decision authority.)

______Printed Name / Signature CONTINUED TU RN ED BO AT IS FL OA TIN G IN A LA RG E LAK E OR RIV ER, HA NG ON TO CR AFT AN D DO NO T ATT EM PT TO SWI M TO SH OR E UN LES S AN 18 14. NEGLIGIBLE MODERATE SERIOUS CRITICAL Remaining (AFS Manager/Associate (State Risk Level (Task Leader) (Branch Chief) Manager) Director/Associate) After X 15. RISK DECISION AUTHORITY: (Approval/Authority Signature Block) (If Initial Risk Level is CRITICAL, SERIOUS or MODERATE: Brief Risk Decision Authority at that level on Controls and Control Measures used to reduce risks) (Note: if the person preparing the form signs this block, the signature indicates only that the appropriate risk decision authority was notified of the initial risk level, control measures taken and appropriate resources requested; and that the risk was accepted by the decision authority.)

______Printed Name / Signature CONTINUED ED DY IS PR ES EN T

- ST AY UP ST RE AM OF OV ER TU RN ED CR AFT TO AV OID BEI NG PIN NE D AG AIN ST AN Y OB ST AC LES IN TH E WA 19 14. NEGLIGIBLE MODERATE SERIOUS CRITICAL Remaining (AFS Manager/Associate (State Risk Level (Task Leader) (Branch Chief) Manager) Director/Associate) After X 15. RISK DECISION AUTHORITY: (Approval/Authority Signature Block) (If Initial Risk Level is CRITICAL, SERIOUS or MODERATE: Brief Risk Decision Authority at that level on Controls and Control Measures used to reduce risks) (Note: if the person preparing the form signs this block, the signature indicates only that the appropriate risk decision authority was notified of the initial risk level, control measures taken and appropriate resources requested; and that the risk was accepted by the decision authority.)

______Printed Name / Signature CONTINUED TE R AS BO AT MA Y DRI FT INT O SH OR ELI NE SWAMPED X X *SAME AS BOAT, - IF - SWI ABOVE* SINKING OR OV FT OVERTURNIN ER WA G TU TE RN R ED RE BO SC AT UE IS TE FL CH OA I TIN G IN A LA RG E LAK E OR RIV ER, HA NG ON TO CR AFT 20 14. NEGLIGIBLE MODERATE SERIOUS CRITICAL Remaining (AFS Manager/Associate (State Risk Level (Task Leader) (Branch Chief) Manager) Director/Associate) After X 15. RISK DECISION AUTHORITY: (Approval/Authority Signature Block) (If Initial Risk Level is CRITICAL, SERIOUS or MODERATE: Brief Risk Decision Authority at that level on Controls and Control Measures used to reduce risks) (Note: if the person preparing the form signs this block, the signature indicates only that the appropriate risk decision authority was notified of the initial risk level, control measures taken and appropriate resources requested; and that the risk was accepted by the decision authority.)

______Printed Name / Signature CONTINUED AN D DO NO T ATT EM PT TO SWI M TO SH OR E UN LES S AN ED DY IS PR ES EN T - ST AY UP ST RE AM OF OV ER TU RN ED CR AFT TO AV OID 21 14. NEGLIGIBLE MODERATE SERIOUS CRITICAL Remaining (AFS Manager/Associate (State Risk Level (Task Leader) (Branch Chief) Manager) Director/Associate) After X 15. RISK DECISION AUTHORITY: (Approval/Authority Signature Block) (If Initial Risk Level is CRITICAL, SERIOUS or MODERATE: Brief Risk Decision Authority at that level on Controls and Control Measures used to reduce risks) (Note: if the person preparing the form signs this block, the signature indicates only that the appropriate risk decision authority was notified of the initial risk level, control measures taken and appropriate resources requested; and that the risk was accepted by the decision authority.)

______Printed Name / Signature CONTINUED BEI NG PIN NE D AG AIN ST AN Y OB ST AC LES IN TH E WA TE R AS BO AT MA Y DRI FT INT O SH OR ELI NE - AV OID AP PR OA CHI NG LO GS IN TH E 22 14. NEGLIGIBLE MODERATE SERIOUS CRITICAL Remaining (AFS Manager/Associate (State Risk Level (Task Leader) (Branch Chief) Manager) Director/Associate) After X 15. RISK DECISION AUTHORITY: (Approval/Authority Signature Block) (If Initial Risk Level is CRITICAL, SERIOUS or MODERATE: Brief Risk Decision Authority at that level on Controls and Control Measures used to reduce risks) (Note: if the person preparing the form signs this block, the signature indicates only that the appropriate risk decision authority was notified of the initial risk level, control measures taken and appropriate resources requested; and that the risk was accepted by the decision authority.)

______Printed Name / Signature CONTINUED WA TE R AT TH E SU RF AC E OR SLI GH TLY SU BM ER GE D - DIS TRI BU TE WEI GH T OF CA RG O AN D PE RS ON NE L EV EN LY AR OU ND 23 14. NEGLIGIBLE MODERATE SERIOUS CRITICAL Remaining (AFS Manager/Associate (State Risk Level (Task Leader) (Branch Chief) Manager) Director/Associate) After X 15. RISK DECISION AUTHORITY: (Approval/Authority Signature Block) (If Initial Risk Level is CRITICAL, SERIOUS or MODERATE: Brief Risk Decision Authority at that level on Controls and Control Measures used to reduce risks) (Note: if the person preparing the form signs this block, the signature indicates only that the appropriate risk decision authority was notified of the initial risk level, control measures taken and appropriate resources requested; and that the risk was accepted by the decision authority.)

______Printed Name / Signature CONTINUED TH E BO AT, SE CU RE CA RG O LO AD S

BAD X X *SAME AS WEATHER - AL - PR ABOVE* WA E YS TRI CH P EC PLA K NNI DAI NG, LY AM WE P AT ST HE UD R Y, RE ME PO ETI RT NG IF WIT AV H AIL PE ABL OP E LE EX - ST PE OP RIE AN NC D ED 24 14. NEGLIGIBLE MODERATE SERIOUS CRITICAL Remaining (AFS Manager/Associate (State Risk Level (Task Leader) (Branch Chief) Manager) Director/Associate) After X 15. RISK DECISION AUTHORITY: (Approval/Authority Signature Block) (If Initial Risk Level is CRITICAL, SERIOUS or MODERATE: Brief Risk Decision Authority at that level on Controls and Control Measures used to reduce risks) (Note: if the person preparing the form signs this block, the signature indicates only that the appropriate risk decision authority was notified of the initial risk level, control measures taken and appropriate resources requested; and that the risk was accepted by the decision authority.)

______Printed Name / Signature CONTINUED WAI IN T TH OU AT T TY BA PE D OF WE WA AT TE HE R R OR - DAI WA LY TE PR R E- CO TRI NDI P TIO BRI NS EFI NG S AN D SA FET Y RE MIN DE RS LOST, X X *SAME AS BROKEN - AL - PR ABOVE* DOWN OR WA E- STRANDED YS TRI CA P RR PLA Y NNI RA NG, DIO MA , P SA ST TEL UD LIT Y, E ME TEL ETI 25 14. NEGLIGIBLE MODERATE SERIOUS CRITICAL Remaining (AFS Manager/Associate (State Risk Level (Task Leader) (Branch Chief) Manager) Director/Associate) After X 15. RISK DECISION AUTHORITY: (Approval/Authority Signature Block) (If Initial Risk Level is CRITICAL, SERIOUS or MODERATE: Brief Risk Decision Authority at that level on Controls and Control Measures used to reduce risks) (Note: if the person preparing the form signs this block, the signature indicates only that the appropriate risk decision authority was notified of the initial risk level, control measures taken and appropriate resources requested; and that the risk was accepted by the decision authority.)

______Printed Name / Signature CONTINUED EP NG HO WIT NE, H EPI PE RB OP OR LE PLB EX PE - CA RIE RR NC Y ED FLA IN RE TH S AT WIT TY H PE UN OF EX WA PIR TE ED R DA TE - ALL ST FIE AM LD PS WO RK - CA ER RR S Y IN ON RE E MO EX TE TR AR A EA OA S R MU OR ST PA ATT DD EN LE D PE FIR R ST BO AID AT AN - AL D CP 26 14. NEGLIGIBLE MODERATE SERIOUS CRITICAL Remaining (AFS Manager/Associate (State Risk Level (Task Leader) (Branch Chief) Manager) Director/Associate) After X 15. RISK DECISION AUTHORITY: (Approval/Authority Signature Block) (If Initial Risk Level is CRITICAL, SERIOUS or MODERATE: Brief Risk Decision Authority at that level on Controls and Control Measures used to reduce risks) (Note: if the person preparing the form signs this block, the signature indicates only that the appropriate risk decision authority was notified of the initial risk level, control measures taken and appropriate resources requested; and that the risk was accepted by the decision authority.)

______Printed Name / Signature CONTINUED WA R YS TR FIL AIN E ING TRI AN P D PLA ALL N RE WIT QUI H RE OF D FIC RE E, FR CR ES EW HE CHI R EF TR OR AIN LO ING CA L PE OP LE - INS PE CT CR AFT PRI OR TO EA CH TRI P AN D EN SU RE TH AT 27 14. NEGLIGIBLE MODERATE SERIOUS CRITICAL Remaining (AFS Manager/Associate (State Risk Level (Task Leader) (Branch Chief) Manager) Director/Associate) After X 15. RISK DECISION AUTHORITY: (Approval/Authority Signature Block) (If Initial Risk Level is CRITICAL, SERIOUS or MODERATE: Brief Risk Decision Authority at that level on Controls and Control Measures used to reduce risks) (Note: if the person preparing the form signs this block, the signature indicates only that the appropriate risk decision authority was notified of the initial risk level, control measures taken and appropriate resources requested; and that the risk was accepted by the decision authority.)

______Printed Name / Signature CONTINUED YO UR CR AFT HA S BE EN PR OP ER LY MAI NT AIN ED - AL WA YS CA RR Y EX TR A FO OD, CL OT HIN G AN D SU PPL IES WH EN TR AV ELI NG TH RO UG 28 14. NEGLIGIBLE MODERATE SERIOUS CRITICAL Remaining (AFS Manager/Associate (State Risk Level (Task Leader) (Branch Chief) Manager) Director/Associate) After X 15. RISK DECISION AUTHORITY: (Approval/Authority Signature Block) (If Initial Risk Level is CRITICAL, SERIOUS or MODERATE: Brief Risk Decision Authority at that level on Controls and Control Measures used to reduce risks) (Note: if the person preparing the form signs this block, the signature indicates only that the appropriate risk decision authority was notified of the initial risk level, control measures taken and appropriate resources requested; and that the risk was accepted by the decision authority.)

______Printed Name / Signature CONTINUED H RE MO TE AR EA S - AL WA YS CA RR Y A WE LL ST OC KE D FIR ST AID KIT

RISK MANAGEMENT WO RK SH EET IN STRU CTIO NS 1. Organization conducting the risk assessment and the location of the operation. 2. If more than one page is used, indicate number of pages. (For example: Page 1-3) 3. In general terms, identify the operation/task(s) to be performed. 4. Enter the date that the operation/task(s) is to begin. 5. Enter the date that the operation/task(s) is to end.

29 6. Enter the date that the risk assessment was prepared. 7. Enter the name and the duty position of the person completing the form. 8. Identify specific hazards associated with the operation/task(s). It is important to be specific and start at the beginning - the preparation phase (e.g., equipment draw/transportation of equipment) of the operation. (For example; unfamiliar equipment, inexperienced operators, improperly configured equipment, challenging terrain, natural hazards, hazardous chemical use, span of supervision, location of work, types of roads, confined spaces, pinch points, etc.) 9. Assess the initial risk using the risk assessment matrix. 10. Identify control measures for each identified hazard in block 8. 11. Assess the residual risk - the risk remaining after the control measures are taken into consideration using the risk assessment matrix. 12. Identify how the controls will be implemented. (For example; SOPs, tailgate safety briefings, written/oral policy statements and/or directions, familiarization training, ‘Right to Know’ training, use of PPE, use of spotters, etc.) 13. Enter the specific individual(s) or method(s) used to supervise and evaluate the provisions of the risk assessment. (For example; supervisor/leader on site, buddy system, and/or employee cross-talk.) 14. Circle the appropriate remaining level of risk. 15. The authority accepting the risk should sign this block. If the authority is notified and accepts the risk, the person completing the form can note same and sign block 15. (See Note in block 15.)

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