Title Page
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Site
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Conducted on
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Supervisor Name
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Weather Temp:
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Weather Conditions:
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Description of Tasks
Untitled Page
Hazard Identification
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Have you signed in and out on site?
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Do you have the required PPE for the tasks?
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Are the environmental hazards identified and adequately controlled?
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Are the noise hazards identified and adequately controlled?
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Are the working at heights hazards identified and adequately controlled?
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Are the confined space hazards identified and adequately controlled?
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Have the movement of mobile plant hazards identified and adequately controlled?
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Have the mechanical lifting hazards identified and adequately controlled?
Specific Control Measures
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Are all personnel fit for work?
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Are JSEAs available?
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Are SWMS for the tasks completed and available?
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Are the operators aware of pre-start inspections on the plant equipment?
Current Permits:
Current Environmental Focus:
Did we achieve the plan yesterday?
Areas of Improvement?
Remember to complete your “Stop & Think” Task Assessment Today
ATTENDANCE / ACTION RECORD
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Name
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Signature
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Supervisor Signed:
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Date: