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Fall Hazard Assessment
Date Conducted:
Assessment Completed By:
Facility Name:
Describe the Fall Hazard (include reasons for an exposure to a fall)	Duration of the Work (time in hours)	Maximum Potential Fall Distance	Obstructions In the Fall Path	Method of Access to the Fall Hazard Workplace	Severity of a Fall - 1 is Low, 5 is High	Frequency of Exposure - 1 is Low, 5 is High	Risk Rating = Severity X Frequency