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75 <br /> <br /> <br /> <br /> (√) <br />If Present Potential Hazard Potential Harm <br /> Source And Location Of Hazard <br />(identify hazard) <br /> <br /> OTHER HAZARDS <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />This checklist provides general guidance for the identification of common work place hazards. It is not all-inclusive. The employer must customize the form for the specific work place.