Title Page
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Site conducted
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Date
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PPE Check
- Hard hat
- Safety Boots
- High Vis
- Glasses
- Gloves
- Ear Protection
- Other (add notes)
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Location of the works
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Job No.
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Job description
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Please upload a photo of the Work Authorisation Form (WAF)
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No. of Workers
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Safety Passport Checked
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List additional / key hazards
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Control Measures - Method Statement
- BPMS01 Inspection and Basic Maintenace at ground level
- BPMS03 Inspection and Basic Maintenace at Heigh Level
- BPMS04 Cleaning at Height
- BPMS05 CO2 Pack
- BPMS06 High Level Inspection & Maintenace from MEWPs
- BPMS07 Refrigeration Inspection & Planned/ Reactive Maintenace
- BPMS09 Inspection and Deep Oven/Fridge Clean
- BPMS10 Electric Works
- BPMS11 Building & Civil Repair Works
- BPMS12 Manchamber Access For Electrical Repairs
- BPMS13 oven Microwave and Hot Display Unit Repairs and Replacement
- BPMS14 safe Use of Mobile Tower Scaffold
- BPMS15 Pressure Washing Packs & Air Con Unit
- BPMS16 Installation of Ice Machine
- BPMS17 Shop RooF Gutter Clean & Inspection
- BPMS19 Duct Sealing in Inspection chamber
- BPMS20 ACO drainage Sump Pump unit installation with mechanical lift
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Control Measure - Risk Assessment - General
- N/A
- BPRA G 01 - Safe Use of Podium Steps B Deck Extra Wide Steps
- BPRA G 02 - Hand Arm Vibration
- BPRA G 03 - Manual Handling
- BPRA G 04 - Use of Portable Power Tools
- BPRA G 05 - Noise
- BPRA G 06 - Safe Use of Bratts Platform Steps
- BPRA G 07 - Safe Use of Tower Scaffolds
- BPRA G 08 - Lone Working
- BPRA G 09 - Oven Microwave and Hot Display Unit Repairs and Replacement
- BPRA G 10 - Covid-19 Measures
- BPRA G 11 - Working in Close Proximity to Others
- BPRA G 12 - Travelling in vehicles During COVID Pandemic
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Control Measure - Risk Assessment - Electrical
- N/A
- BPRA E 01 -Working on Low Voltage Dead Electrical Systems
- BPRA E 02 - Working on or near Low Voltage Live Electrical Systems
- BPRA E 03 - Cable Pulling and installation
- BPRA E 04 - Removing and installing luminaires
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Control Measure - Risk Assessment - Fridge
- N/A
- BPRA C 01 - Deep Oven Fridge Clean
- BPRA F 01 Pressure Testing of Refrigeration Pipework Systems
- BPRA F 02 Leak Testing
- BPRA F 03 Pump down of Refrigerant
- BPRA F 04 Refrigerant Removal and Handling
- BPRA F 05 Refrigerant Charging
- BPRA F 06 Fault finding inspection of refrigeratged systems
- BPRA F 07 Refrigeration Commissioning
- BPRA F 08 Use of oxyacetylene packages and cylinders
- BPRA F 09 Working on top of Coldrooms for maintenance works
- BPRA F 10 Use of Compressers
- BPRA F 11 Working With C02
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Control Measure - Risk Assessment - Building
- N/A
- BPRA B 04 - Safe Use of Petrol driven high pressure cleaner
- BPRA B 05 - Inspection and Maintenance from Vehicle Mounted Access Platforms
- BPRA B 05 App 1 Nationwide VMB Rescue Plan
- BPRA B 06 - General Plumbing
- BPRA B 07 - General Painting
- BPRA B 08 - Making Safe Broken Glass
- BPRA B 09 - Dismantling and Erecting Suspended Ceilings
- BPRA B 10 - Minor Building Works
- BPRA B 11 - Abrasive Wheels
- BPRA B 12 - General Carpentry and Joinery
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Control Measures - BP Golden Rules
- Hot Works
- Working at height
- Permit to work
- De-energising
- Driving Safely
- Ground Disturbance
- Lifting Operation
- Confined Spaces
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Additional / key control measures
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Has this clearance certificate been amended during the task
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Please note what these changes are
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Additional control measures for chemicals (included coshh assessments name)
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A new clearance certificate is required if additional hazards emerge during the works. IF UNSAFE - STOP WORK!.
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Site Personnel Authorisation. (City FM Technician) I confirm I have read and understood the constraints imposed by the Safety Method Statement and the precautions identified above and will ensure that the above work is carried out in accordance with them.
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Forecourt Site Manager Confirmation I confirm that I have informed the contractor of the site emergency plan and other hazards outside their control e.g. other contractors, tanker deliveries etc.
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Forecourt Site Manager Sign off I confirm the works have been completed to my satisfaction and the work areas have been left safe and tidy
