HNZ MTN ASSURANCE

• Program Name

• Reason for visit

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Pre-site checks

• Have you checked the CRIP rating - if the property is tenanted

  Yes

  No

  N/A

• Have you checked the property/surrounds risk information

  Yes

  No

  N/A

• Have you completed a SWP if needed<br>

  Yes

  No

  N/A

• Have you arranged the visit as per established protocols and notified others

  Yes

  No

  N/A

Self assessment and Situational Awareness

• Is my Secure Locate activated

  Yes

  No

  N/A

• Is it safe to exit my vehicle

  Yes

  No

  N/A

• Is the site secure and safe to enter

  Yes

  No

  N/A

• Am I wearing the correct PPE

  Yes

  No

  N/A

Site Assessment Mandatory Section

• Is access control effective, no unauthorised access

  Yes

  No

  N/A

• Is the Hazard/Risk Register board in place

  Yes

  No

  N/A

• Has the Hazard/Risk Register board been updated today

  Yes

  No

  N/A

• Are the PPE requirements displayed

  Yes

  No

  N/A

• Is signage in place and appropriate for risk (e.g. report to site office, no entry, asbestos, danger)

  Yes

  No

  N/A

• Is induction or discussion of site risks held

  Yes

  NA (No workers on site)

  No (Do not proceed with visit)

• Do the risks mentioned match the Hazard/Risk Register board

  Yes

  No

  N/A

• Are PPE requirements described

  Yes

  No

  N/A

• Is the induction/discussion recorded

  Yes

  No

  N/A

Site Assessment Optional Section depending on activities on site/to be targeted

• Emergency Equipment Section

  Selected

• Is a fire extinguisher available

  Yes

  No

  N/A

• Is the first aid kit complete and available

  Yes

  No

  N/A

• Is a spillage kit on site

  Yes

  No

  N/A

• Are risk specific Emergency Response Plans available and easy to access

  Yes

  No

  N/A

• Are emergency numbers available and easy to access

  Yes

  No

  N/A

• Documentation Section

  Selected

• Are clearance certificates on site e.g. asbestos, methamphetamine

  Yes

  No

  N/A

• Is a SSSP available on site

  Yes

  No

  N/A

• Are safety meeting minutes added to SSSP

  Yes

  No

  N/A

• Is the SSSP in daily use

  Yes

  No

  N/A

• Is SSSP content known on site

  Yes

  No

  N/A

• Are SDS available and easy to access

  Yes

  No

  N/A

• If asbestos being removed, is an Asbestos Removal Control Plan at site and being followed

  Yes

  No

  N/A

• Site housekeeping and facilities Section

  Selected

• General site tidy and orderly, free of trip hazards

  Yes

  No

  N/A

• Are materials stacked safely

  Yes

  No

  N/A

• Are stacking areas demarcated

  Yes

  No

  N/A

• Are hazards demarcated (e.g. trenches)

  Yes

  No

  N/A

• Are waste materials stored in bins

  Yes

  No

  N/A

• Are bins used for hazardous materials lined

  Yes

  No

  N/A

• Are toilet facilities and running water accessible on site

  Yes

  No

  N/A

• Are exposed reinforcing bars capped

  Yes

  No

  N/A

• Personnel on site Section

  Selected

• ID tags carried and current

  Yes

  No

  N/A

• Supervisor or designated backup available on site during visit

  Yes

  No

  N/A

• PPE and manual handling Section

  Selected

• Are requirements known on site

  Yes

  No

  N/A

• Are all workers wearing correct PPE

  Yes

  No

  N/A

• Are acceptable manual handling methods being used for tasks observed

  Yes

  No

  N/A

• Working at Height Section

  Selected

• Has the most appropriate equipment been chosen for work at height e.g. scaffolding, mobile scaffolding, elevated platform, ladder

  Yes

  No

  N/A

• If work is being conducted within 4m of overhead power lines is effective isolation in place (e.g. power disconnection, sleeving, or close approach consent).

  Yes

  No

  N/A

• Scaffolding Section

  Selected

• Is the tag valid (present, weekly inspection recorded, completed in full)

  Yes

  No

  N/A

• If the scaffolding exceeds 5m in height has WorkSafe been notified (does not apply if single storey home)<br>

  Yes

  No

  N/A

• If the scaffolding exceeds 5m in height has it been erected by a holder of a current certificate of competence

  Yes

  No

  N/A

• Is scaffolding installed to standard (e.g. soleboards 500mm x 200mm x 38mm thick, base boards, platforms, toe boards, stabilising legs, stand offs, gates, ladder attachments, edge protection installed effectively)

  Yes

  No

  Unable to assess

• Ladders Section

  Selected

• Is the ladder set up at 1:4 ratio (1m horizontal to 4m vertical)

  Yes

  No

  N/A

• Can users maintain 3 points of contact at all times

  Yes

  No

  N/A

• Is the ladder secured at top and base to prevent slipping sideways/out

  Yes

  No

  N/A

• Do all ladders have more than 3 steps

  Yes

  No

  N/A

• Power Supply Section

  Selected

• Are safety devices in place

  Yes

  No

  N/A

• If power isolated is a lock out device in place with tag

  Yes

  No

  N/A

• Have power source (e.g. distribution box) leads been tagged

  Yes

  No

  N/A

• Are tags valid and leads in good working order

  Yes

  No

  N/A

• Are leads used in a safe manner

  Yes

  No

  N/A

• Tools & Machinery Section

  Selected

• Are power tool tags valid

  Yes

  No

  N/A

• Are safety devices operable i.e. not tampered with

  Yes

  No

  N/A

• Are the right tools or machinery being used for the job

  Yes

  No

  N/A

• Are all dangerous parts guarded

  Yes

  No

  N/A

• Do all tools and machinery appear to be in good working order

  Yes

  No

  N/A

• Hazardous Substances Section

  Selected

• Is dust control in place at source for respirable dust and/or paint particles e.g. timber, silica, lead based paint

  Yes

  No

  N/A

• Is waste from any dust extraction system disposed of safely

  Yes

  No

  N/A

• Is correct PPE for cutting activities worn (e.g. ear protection, eye protection, P2 dust mask)

  Yes

  No

  N/A

• Are lead test results on site

  Yes

  No

  N/A

• Are lead containment controls sufficient and in good condition (e.g. plastic sheeting ground cover, sealed openings) <br>

  Yes

  No

  N/A

• Is HNZ permitted method used for lead based paint removal (chemical stripping, wet scraping, wet hand sanding) <br>

  Yes

  No

  N/A

Positive Observations

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  Media

Opportunities for improvement

• Add media

  Media

Actions completed at site

• Add media

  Media

Agree future/corrective actions

• Add media

  Media

General comments

• Add media

  Media