KY Hazard & Risk Prediction Sheet

Page 1 of 8 – A. WORK INFORMATION

Applicant Type *  Date *  Start Time *  End Time *  Weather *  Department / Section *  Supervisor / Foreman *  Detail of Work Activity *  Routine / Non‑Routine Work *  Number of Workers * 

Page 2 of 8 – B. ACTIVITY TO BE DONE – PHOTO ATTACHMENT

Attach photos of the work area, equipment, and activity.

Activity photos *  Pointing and Calling photos * 

Page 3 of 8 – C. RISK FACTORS

High Places / Work at Heights Flammable Materials High Temperature / Hot Work Heavy Equipment Confined Space High Pressure Fluid Opening of Machines Harmful Chemicals Others

Page 4 of 8 – D. WORK SEQUENCE, HAZARDS, RISKS & CONTROLS

Work Sequence	Danger	Risk Before Control	Countermeasure	Required PPE	Risk After Control
		-			-
		-			-
		-			-
		-			-
		-			-

Page 5 of 8 – E. PRIORITY GOALS 

Page 6 of 8 – F. PERSONNEL INVOLVED

Page 7 of 9 – G. LOTOTO REQUIREMENT

YES NO

Page 8 of 9 – H. LOTOTO DETAILS

No.	Equipment No.	Locked (✓)	Time Locked	Unlocked (✓)	Time Unlocked	Equipment Photo

First Approvers

Work In-Charge email

Area In-Charge email

CCR / Production email

Mechanical email

E / I email

Page 9 of 9 – I. FINAL APPROVAL

Final Approvers

Thank you!

Your KY Hazard & Risk Prediction Sheet has been submitted.

Your KY form number is . Keep it to check the application status.

KY Hazard & Risk Prediction Sheet

Check KY application status

Page 1 of 8 – A. WORK INFORMATION

Page 2 of 8 – B. ACTIVITY TO BE DONE – PHOTO ATTACHMENT

Page 3 of 8 – C. RISK FACTORS

Page 4 of 8 – D. WORK SEQUENCE, HAZARDS, RISKS & CONTROLS

Page 5 of 8 – E. PRIORITY GOALS

Page 6 of 8 – F. PERSONNEL INVOLVED

Page 7 of 9 – G. LOTOTO REQUIREMENT

Page 8 of 9 – H. LOTOTO DETAILS