Annex 1 - Risk assessment and area handover - UKIEPL

• Site conducted

• Conducted on

  Date

• Prepared by

• Location
  Address

• Client:

• Date:

  Date

• Who is performing the survey

  Select

• Contractor's Name

• Contractor's CUI

• MG

• The Client undertakes to offset temporally and spatially any work of its own or of other subjects, in the areas affected by the work to avoid any possible risk resulting from interference between the activities

1. General company/area information and contact persons of the contract

• Business area covered by the contract (address):
  Address

• Name of the person who will supervise access to the work areas:

• Telephone, fax, and e-mail numbers:

2. Work area

• controlled areas with regulated access:

• description:

• open areas:

• description:

• LV/MV/HV electrical cabins

• parking/outdoor areas

• service/storage room

• working on roofs

• other (specify)

• Attach any technical documentation (e.g., plans)

  Media

3. Working on roofs

• Does this activity involve working on roofs?

  Yes

  No

• The system of access to the covers has the following characteristics:

• presence of masonry staircase with parapets

• rungs ladder secured to the building

• rungs ladder against the wall

• rungs ladder secured to the building with inclination greater than 75° with protective cage (cage ladder)

• scaffolding (which requires technical documentation for safe access)

• no opportunity for access

• Covering has the following characteristics:

• presence of railings and covering completely walkable or in any way walkable in the area to reach during site/activity inspection

• absence of railings and covering completely walkable or in any way walkable in the area to reach during site/activity inspection

• absence of parapets, with walkable covering or walkable in the area to reach during the survey/activity, equipped with lifelines or anchorage points

• If the cover does not have safe access and/or is not equipped with railings, it will be necessary to conduct a cover survey using Aerial Working Platforms (lift equipment) and/or DRONE. The customer undertakes, if necessary, from the results of the inspection, to provide areas where it is possible to install provisional works and/or other equipment to conduct the activities

4. Think through the task

• Do you understand the task :

  Yes

  No

• Do you understand the steps to do the task :

  Yes

  No

• Are your tools/equipment in good order :

  Yes

  No

• Do you have the correct PPE :

  Yes

  NO

• Do you understand the RAMS for this task :

  Yes

  NO

• Do you know where all the emergency arrangements are located (Fire Assembly/First Aid etc)

  Yes

  No

5. SPOT THE HAZARD

• inadequate lighting

• Description:

• Add control measure

• internal and external traffic

• Description:

• Add control measure

• hot/cold (vapour or liquid) lines

• Description:

• Add control measure

• presence of subservice systems: water, gas, electric

• Description:

• Add control measure

• was the presence detected?

  Yes

  No

• confined spaces, cisterns, tanks, trapdoors

• Description:

• Add control measure

• microclimate

• Description:

• Add control measure

• presence of incendiary material

• Description:

• Add control measure

• presence of material/ waste deposits

• Description:

• Add control measure

• explosive materials

• Description:

• Add control measure

• noise

• Description:

• Add control measure

• electromagnetic fields

• Description:

• Add control measure

• artificial optical radiation

• Description:

• Add control measure

• hazardous chemical agents

• Description:

• Add control measure

• carcinogens/mutagens agents

• Description:

• Add control measure

• biological agents

• Description:

• Add control measure

• dust, risk of inhalation

• Description:

• Add control measure

• uncontrolled emission from system

• Description:

• Add control measure

• presence of asbestos

  Select

• Refer to RAMS

• other:

• Description:

• Add control measure

• Is it safe to proceed with the task :

  Yes

  No

• Description:

• Date:

  Date

• Owner/Client signature

  Sign

• * The Owner/Client sign are required if this form is not attached to preventive quotation

• Owner/Client decides not to sign

• Workers' sign

  Sign

• Workers' sign

  Sign

• Workers' sign

  Sign

• Workers' sign

  Sign

6. Survey’s finding transfer

• Who is performing the survey

  Select

• The Contractor’s Employer declares that is aware of the specific risks existing in the working area communicated by this form, of the specific requirements agreed and/or received by the Customer’s Safety Representative (if any)/Customer who undertakes to comply with the planned measures, the laws, to carry out their activities in compliance with the good manufacturing practices and organizes the work through appropriate procedures implementing the protection and prevention actions following their own risk assessment for the work to be carried out

• Date:

  Date

• Contractor Employer’s signature and stamp

  Sign

7. Realization of activities – Areas’ handover

Start of activities

• Date&Time

  Date

• I, the undersigned site supervisor,

• confirm the validity and completeness of the above information, necessary and sufficient to safely take over the area for the development of the expected activities, the adoption of prevention and protection measures provided for these by the Executor. Clearance to proceed

• Foreman's Sign

  Sign

• Workers' sign

  Sign

• Workers' sign

  Sign

• Workers' sign

  Sign

• Workers' sign

  Sign

• Is a 1st transfer required

  Yes

  No

• 1st transfer to another Foreman’s Executor

• Personnel Involved:

• Date and time

  Date

• Area conditions and work progress

• Name of the Foreman’s Executor

• Foreman's Sign

  Sign

• Worker's sign

  Sign

• Worker's sign

  Sign

• Worker's sign

  Sign

• Worker's sign

  Sign

• Is a 2nd transfer required

  Yes

  No

• 2nd transfer to another Foreman’s Executor

• Personnel Involved:

• Date and time

  Date

• Area conditions and work progress

• Name of the Foreman’s Executor

• Foreman's Sign

  Sign

• Worker's sign

  Sign

• Worker's sign

  Sign

• Worker's sign

  Sign

• Worker's sign

  Sign

A sub-contractor transfer

• Is a sub-contractor transfer required

  Yes

  No

• Date & Time

  Date

• I, the undersigned,

• SubContractor’s foreman

• confirm that as shared by Contractor’s Foreman, is aware, of the presence of the risks of the working area/environment as indicated above and/or here indicated in detail:

• and confirm the validity and completeness of the information received, necessary and sufficient to safely take over the area for the development of the expected activities, in the adoption of the prevention and protection measures provided by our company area risks and the prevention and protection measures to be taken by our workers to perform the activities and confirms the validity of the above information and take over the area for carrying out the activities. Clearance to proceed

• Sign

  Sign

Completed activities – Areas’ hand back

• Date & Time

  Date

• The undersigned

• assignee of the activities, declares concluded the operations and safely returns the area to the owner without any additional risks compared to the activity starts.

For the Contractor

• Sign

  Sign

Owner/Client

• Sign

  Sign

Post-job review

• Did any issues emerge during/after operating activities?

  Yes

  No

• Brief description of the event / context relevant to security identified during the activity and worthy of generalization / discussion

• Foreman's Sign

  Sign

• Worker's sign

  Sign

• Worker's sign

  Sign

• Worker's sign

  Sign

• Worker's sign

  Sign