Information

  • Title

  • Presented by (name)

  • Worksite Manager

  • Email

  • Date

  • Estimate finish works date.

  • Address (Workplace) and GPS Coordinates:
  • Activity / Project Description

  • Worksite Supervisor / Ganger in charge of site

  • Additional acting worksite supervisor / ganger in charge of site

  • Health and Safety Representative (HSR) on site (add name if yes)

Prior to works commencing check the following has been completed

  • Work activities planned and communicated to worksite managers e.g., supervisors/gangers?

  • Worksite job pack and activities communicated to worker in office or onsite? (SWMS activities must be communicated to workers).

  • Prepared by (optional)

Mobile works (multiple worksites)

    WORKSITE
  • Worksite details, add location and brief description if attending multiple worksites (Includes TAKE 5 Risk assessment)

  • Site location or address
  • Date and time

  • Add brief description of works undertaken

  • TAKE 5 (Risk assessment - Add details and take photo if required)

  • HRCW triggers. NOTE: If any controls shown are selected, then the work is High Risk Construction Work (HRCW), and the SWMS section must be completed.

  • SWMS required? If unsure whether it is HRCW or not, call a WHS Officer or the People and Culture Manager to clarify.

  • High Risk Construction Work (HRCW) - SWMS required or Minor Works only (If SWMS, open SWMS page and select controls).

Worksite check

  • Completed worksite job pack in consultation with your team?

  • Worksite setup properly (Safer for operations to commence)

  • Worksite safety monitored to ensure work activities and systems are conducted safely?

  • Workers reminded to work safe and immediately report any safety issues?

1. Project induction checklist and emergency details

  • NOTE: Every element has an - add NOTES or MEDIA (photo) feature that can be used e.g., to add more information or pics as required. Pictures may also be downloaded from the device picture library.

  • First aid officer(s) on site (enter names if required)

  • Location of first aid kit (enter detail of location(s) if required) e.g., in vehicles and site caravan.

  • Fire extinguisher location?

  • Location of site specific amenities e.g. toilet and rest room (enter detail of location if required)

  • Workers must not use mobile phones while working particularly, spotters, plant operators and traffic controllers.

  • Site orientation provided (enter detail if required)

  • Site access and egress identified and clear in the event of an emergency?

  • EMERGENCY PLAN DISCUSSED (Call 000 in an emergency)?

  • Emergency contacts list available and location identified (Add name of emergency contact(s) in notes)

  • Location of emergency evacuation point (enter detail of location if required)

  • For emergencies call triple 000 requiring immediate assistance
    WHS Officer : Wayne Cameron - 0418 698 441 WHS Officer : Peter Brunt - 0400 906 862
    People and Culture : Fran Summerfield - 0427 487 736
    Remember! Call your manager asap. For notifiable or potential notifiable incidents to SafeWork NSW you must immediately call a WHS Officer
    SafeWork NSW 13 10 50

  • Select types discussed

  • Workers working in close proximity to plant i.e. inside 10 metre exclusion zone must be inducted into exclusion permit details

2. Toolbox talk

    Toolbox
  • Presenter

  • Date and time

  • TOOLBOX (Agenda, discussion and any actions).

  • Agenda Items / Topics

  • Discussion

  • Actions

  • Person responsible to action (if required)

  • Due date and time for action closed out.

  • Name of person who completed action and (signature optional)

  • Duties specific to activity discussed (Reminder to workers of those duties)

  • SPOTTER duties discussed

  • Spotter must not undertake any other role while on spotting duty. Spotter must only spot for one service at a time! Spotter understands powerline clearances and voltage levels (must be trained in overhead powerline and underground services). Spotter must not use phone while spotting! Spotter not to have toilet breaks unless discussed with plant operator.

  • TRAFFIC controller duties discussed.

  • Report any near misses or concerns with traffic flow to supervisor without delay. Do not use mobile phone or music devices in your ear while controlling traffic.

  • High vis long sleeve shirt and broad brim hat are required per council policy

  • Use radio channel number:

  • Tickets checked

  • Site specific SWMS checked

  • Worker attendance
  • Worker name and signature if required

3. Personal protective equipment (PPE)

  • Select requirements identified and discussed as required.

  • Council issue hardhats and/or sunhats to be worn on site as per UVR Policy

  • All staff working in an outdoor environment must wear their allocated sun protection personal protective (PPE) equipment. Council understands it is impractical to wear all PPE, such as hats, in every situation and a reasonable tolerance is provided for actions such as walking between buildings, to a vehicle etc. Otherwise all PPE must be worn. E.g. PPE - Broad brim hardhats or legionnaire style caps and Council issue sunhats

  • Personal Protective Equipment (PPE) used on site

  • Other PPE identified (add detail)

  • Other identified worksite requirements (Provide detail)

4. SWMS and SWP

  • SWPs available on site and workers inducted and signed on?

  • Attach generic SWPs needed to reference onsite e.g. GENSWP_003 COR, GENSWP_013 Site prep etc.

Safe Work Method Statements (SWMS)

  • Job description? (Add in notes)

  • Insert location
  • Date and time

  • SWMS Prepared and approved by (name and signature)

  • Control measures to be reviewed (and revised if necessary on site ) if work tasks/methods change or unexpected issues arise or if identified during a TAKE 5. Worker/HSR identifies a deficiency within the SWMS.

SAFE WORK METHOD STATEMENT RISK CONTROLS (Tasks, hazards/risks and controls implemented)

  • Add other controls in NOTES ,and relevant SWP selected via MEDIA i.e. GENSWP_015 Traffic control. SWPs are the foreseeable inherent risks within activity / task and are to be used for guidance on controls required or, further reference to controls to be applied.

  • Enter all detail in primary step or, select step controls and add further steps as required.

  • HRCW hazards and risks requiring controls (IF A RISK IS SELECTED THAN CONTROLS MUST BE SPECIFIC TO THE WORKSITE. THERE MAY BE MORE THAN ONE CONTROL FOR THE SAME RISK SELECTION).

  • TRAFFIC CONTROL (Site set-up)
  • Traffic control required?

  • Refer traffic control SWP (Select media to load link)

  • Traffic controllers must not use mobile devices while on duty

  • Council TCP

  • Contractor TCP

  • Traffic controllers used to set up site

  • Spotters used to set-up site due to low risk location?

  • Contractor traffic controllers used to manage site for duration

  • Witches hats / Cones in place (Workers to remain as reasonable 1.2 metres minimum inside cones).

  • Bunting tape/flagging used

  • Temporary portable 1.85 metre fencing used to secure edge or perimeter of work zone

  • Para webbing fencing used.

  • Plastic fence barriers used.

  • Water filled barriers used for site

  • Date and time

  • Signs check
  • Signs should be checked as still standing and (removed, collapsed or covered when not required).

  • Job open (Insert comments if required).

  • Check by name and (signature optional)

  • Lunch break (Insert comments if required)

  • Check by name and (signature optional)

  • Close of site (Insert comments if required).

  • Check by name and (signature optional)

  • PEDESTRIAN CONTROLS
  • Pedestrian controls required?

  • 1. Place barricading to RMS requirements for delineation of pedestrians and vehicles: a) Consider volume of pedestrians e.g. peak periods b) Consider older pedestrians or people with impairments i.e. visual hearing or physical impairments e.g. walking frames, wheel chairs or the use of ramps

  • 2. Which way will they want to travel from and to: a) Desire lines b) Key routes c) Attractors and links d) Spotters to assist directing pedestrians e) Extra barriers (e.g. crash barriers and crash cushions f) Fence trenches and work areas; locate direction signs

  • 3. Conduct a test walk through when in traffic control in place

  • 4. Observe pedestrians during the daytime and consider night time risks

  • Date and time

  • CYCLIST CONTROLS
  • Cyclist controls required?

  • 1. For cyclists sharing available road space consider: a) Not blocking cycle ways with signage where possible or vehicle cyclists shared corridor: o Signage stating: SHARED CYCLE / VEHICLE ZONE”. o For grooves cycle hazard sign “CYCLE HAZARD GROOVED ROAD” (T2-207) o Existing usage (number of cyclists)

  • 2. Surface and material condition e.g. sweeping of road more frequently e.g. loose stones

  • 3. Available width and alignments for motorists and cyclists

  • 4. Traffic speeds and volumes

  • 5. Duration of work

  • Date and time

  • OVERHEAD POWERLINES (Site set-up)
  • Overhead powerlines controls required?

  • Refer SWP for overhead powerlines (insert in doc via media)

  • Site risk assessment conducted for overhead powerlines

  • Approach distances determined for plant

  • Trained spotter required to support plant (one task only and relieved by operator when finished)

  • Periodic checks for powerlines and operating plant e.g. excavator or tip trucks

  • Meet Essential Energy personnel on site to determine appropriate risk mitigation strategies for overhead and/or underground assets

  • Powerline voltage identified

  • Deenergized power relevant overhead lines

  • Visual tags /tiger tails on overhead lines attached

  • The work site must be assessed for opportunities to conduct the work away from overhead electrical lines. This extends to the parking locations of tip trucks when removing or delivering fill from/for excavations

  • Excavation works within 10m of vertical power poles for overhead lines discussed

  • Comply with approach distance requirements. Only competent WORKERS and approach distance trained workers can spot for approaches inside the ‘ordinary person’ approach distances

  • Ultrasonic cable height indicator used to measure overhead line height and or approach distances (where available).

  • Select date and time

  • UNDERGROUND SERVICES (Excavation)
  • Underground services controls required?

  • Refer excavation and trenching SWP for further detail.

  • Dial Before You Dig (DBYD) completed

  • Underground locator used to locate services

  • VacEx truck used for potholing and exposing underground services (Ref: WWMSWP 003 Vacuum Excavations and/or Excavation GENSWP 011)

  • Trench shields used for 1.5 metre depth and greater

  • Battering undertaken for 1.5 metre depth and greater

  • For unstable and narrow walls less than 1.5m a control select one of above controls

  • A certified geotechnical engineer has provided a report that benching or battering the walls of an excavation, or an angle of repose of 45 degrees may be exceeded. The report details must be complied with.

  • A report available from a geotechnical engineer providing information on the stability and safety of a trench excavation. The report should include details of the soil conditions, any shoring or trench support requirements, dewatering requirements and any longer term effects on stability and safety of the excavation.

  • Intermediate platforms for deep excavations

  • Ensure there is a safe means of movement between different levels of the excavation

  • Back fill excavations as works progress

  • Select date and time

  • DELIVERY OF MATERIALS AND PLANT
  • Delivery of plant and equipment controls required?

  • Site controls

  • Select date and time

  • CRANES includes EXCAVATOR and BACKHOE includes HRWL e.g., dogging.
  • Crane, excavator and/or backhoe controls required?

  • Licensed dogman or rigger onsite to conduct lifting operations?

  • Crane operator licensed for HRWL or, is verified as competent on loadshifting plant?

  • Operator and dogman to communicate when lifting an moving load – dogman in charge giving lifting and shifting instructions

  • Ensure machine is on solid/sound, level ground and outriggers (if fitted) are packed for stability before lifting any load

  • Do not exceed the safe work load limit and work radius<br>limits of the machine (Refer: lifting chart specification)

  • Operators to maintain awareness of nearby workers and plant that may enter work zone

  • Trench edges, embankments to be checked prior to set-up so that they do not collapse from weight of plant and load

  • Caution! Do not pre-empt movement unless ground workers are clear

  • When plant waiting, slew to side and place attachment on the ground clear of workers

  • Follow directions of dogman or spotters as required

  • Select date and time

  • EXCAVATOR and BACKHOE
  • Excavator controls required?

  • Operators to maintain awareness of nearby workers and plant that may enter work zone

  • Worker in trench to have good communication with operator e.g. particularly when lifting, lowering and placing pipes

  • Heavy plant to stay clear of trench edges, embankments so that they do not collapse e.g. when working try to use front or diagonal position to work over trench or embankment.

  • Caution! Do not pre-empt movement unless ground workers are clear

  • When plant waiting, slew to side and place attachment on the ground clear of workers

  • Maintain awareness i.e. conducted head check, check mirrors regularly and check behind when reversing

  • Follow directions of traffic controllers or spotters as required

  • Stop and allow vehicles to pass safely through site when required

  • Maintain awareness of plant movements at all times

  • Select date and time

  • WATER CART
  • Water cart controls required?

  • Follow site rules

  • Maintain communication and follow traffic controller and/or spotter directions

  • Maintain awareness i.e. Regularly and check behind when reversing

  • Follow spotters directions for positioning of truck

  • Maintain awareness of plant movements at all times

  • Give way to other vehicles as required

  • Select date and time

  • GRADER
  • Grader controls required?

  • Maintain awareness i.e. check mirrors regularly and check behind when reversing

  • Follow directions of traffic controllers or spotters as required

  • Stop and allow vehicles to pass safely through site when required – Pull to side if necessary

  • Maintain awareness of plant movements at all times

  • Caution when working near soft edges, embankments or when cutting run-off drains

  • Select date and time

  • TIP TRUCK
  • Tip truck controls required?

  • Operators refer to GENSWP_014 – Tip trucks on construction sites (Specific to operators)

  • Follow site entry rules e.g. observe speed limits

  • Truck operators to communicate with loader operator (loader operator in charge)

  • Truck drivers to remain in vehicle or stand well clear or in a designated location

  • Follow directions of traffic controllers or spotters as required

  • Maintain awareness i.e. check mirrors regularly and check behind when reversing

  • Empty trucks to give way to loaded trucks

  • Check slope and ground conditions are sound before tipping material

  • - Vehicle to stay within maximum gross weight allowable limit - - - No overloading allowed - Loads to be secured (covered) to avoid spillage

  • 10 metre exclusion zone permit completed – All workers are reminded to keep clear of operational plant unless necessary

  • Select date and time

  • DRUM ROLLER / COMPACTOR
  • Drum roller / compactor controls required?

  • Maintain awareness i.e. check mirrors regularly and check behind when reversing

  • Follow directions of traffic controllers or spotters as required

  • Stop and allow vehicles to pass safely through site when required – Pull to side if necessary

  • Maintain awareness of plant movements at all times

  • ake caution when working near road shoulders and soft edges and watch for large rocks and holes near edge of roads

  • 10 metre exclusion zone permit completed – All workers are reminded to keep clear of operational plant unless necessary

  • Select date and time

  • KERB AND GUTTER PLANT
  • Kerb and gutter plant controls required?

  • Workers must be trained in the safe operation of this plant.

  • Follow correct manual handling technique when lifting and using machine

  • Plant must be checked properly before commencement of work to ensure in good operational order

  • All guards must be in place and secure?

  • PPE to be worn when using machine: - Hearing protection - Head protection of risk of being hit on head or mandatory wearing of hardhat signs displayed.

  • Select date and time

  • PROFILER
  • Profiler controls required?

  • Maintain awareness i.e. Regularly and check behind when reversing

  • Follow spotters directions for positioning of truck

  • Maintain awareness of plant movements at all times

  • Do not overload trucks carrying materials

  • Ensure plant to be loaded is positioned on stable ground and positioned correctly for easy and safe loading

  • Load slowly

  • Select date and time

  • WORK AT HEIGHT
  • Work at height controls required?

  • Description of work if required

  • Ref: GENSWP_008 - Work at height

  • All electrical energy power de-energised

  • Roof surface assessed for: - Fragile surface (brittle sheeting on roofs, rusty roofs, fibre glass, skylights etc.) - the potential to slip, for example where surfaces are wet, polished or glazed - the safe movement of workers where surfaces change - the strength or capability to support loads - the slope of work surfaces, for example, where they exceed 7 degrees - levels—where levels change and workers may be exposed to a fall from one level to another

  • Ladder access used secured top and bottom

  • Fall arrest harness with lanyards

  • Anchor points available and

  • Workers on roof to using fall restraint

  • If working at ground level to access pits or wells, workers in fall arrest or restraint

  • Date and time

  • SCAFFOLD
  • Scaffold controls required?

  • Scaffold under 4 metres - training competency only required for e.g. scissor lift or EWP under 11metres

  • Licensed contractor erecting scaffold: HRWL over 4 metres

  • Contractor has SWMS for work

  • Handover or inspection ticket provided

  • Scaffold erected and checked for security e.g. tied and tagged for scaffold over 4 metres.

SWMS CONSULTATION DETAILS

  • All workers consulted on changes (Select SWMS tab on signature page).

  • Reviewed by name and signature

  • Date and time

5. Crystalline silica dust prevention

  • Brief descriptions of work involving silica (e.g., cutting engineered concrete).

  • Does the work and location require air monitoring to determine the airbourne concentration of silica dust in the worker's breathing zone? I.e., in an enclosed environment e.g., workshop cubicle or well etc.

  • Are engineering controls applied to eliminate or minimise the risk? If so, describe.

  • Can Local Exhaust Ventilation (LEV) be used? (Describe type or take photo)

  • Drills , routers, saws and other similar type equipment should be fitted with LEVs (Advise if they are fitted).

  • Sign(s) must be displayed identifying silica dust hazard at this worksite?

  • PPE - Ensure you are wearing the appropriate PPE for the task?

  • Select the correct Respirator and other protective equipment for the task.

  • Is the respirator a good close fit to the face?

  • Is water suppression method being used?

  • Water feed attached to equipment?

  • Adequate number of water feeds directed at the material with a consistent water flow?

  • Guards fitted to mitigate mist containing silica?

  • Site, clothing, plant and equipment cleaned or disposed of to ensure silica dust is not generated when dried out?

6. Asbestos

ASBESTOS

  • If asbestos identified STOP! and contact your manager or WHS section. Refer to the GENSWP_004 - Management of asbestos. If licensed, only manage and handle according to license conditions.

  • Description of asbestos at location

  • Refer: GENSWP_004 - Asbestos management and follow guidance instructions.

  • Refer: Asbestos details form located in SafetyCulture "Asbestos".

  • Date and time

7. Environmental

  • What environmental controls are used on site ?

  • Have these controls been maintained this week ?

  • If yes take photos of controls

  • Environmental Emergency Details

  • Emergency: 1. Confirm with reception (Monitoring Service) at the time of receiving the call that the correct authority has been contacted 2. Ensure Emergency details are clear, concise and correct 3. Details should include: - type of emergency, address, contact details of caller if clarification in needed 4. Refer to list of emergency contact numbers – Police, Fire, Ambulance, Electrical Authority, SES & associated staff 5. Inform relevant authority for assistance 6. Have communications system in place: - mobile phones, two way and UHF radios

  • 1. Approach area with caution – flashing lights engaged 2. Take note of approach hazards 3. Assess site as to what actions need to occur 4. Inform relative authority required of situation & what is needed to make area safe: Police, Ambulance, Fire Brigade, Electrical Authority, HAZMAT, EPA, and SES etc. 5. Contact relevant staff if assistance is required

8. Other party e.g. Contractor or internal council section

    Other party
  • Select other party .e.g. Council section / team or contractor

  • Add contractor company name

  • Authorised person name

  • Office phone (If required)

  • Mobile

  • Email

  • Date

  • Name of worker in charge of their team/work activities

  • Mobile number

  • Inducted/participated in general toolbox talk?

  • Work systems harmonised e.g. work tasks separated, parties can work safely without jeopardising safety of each other (provide detail if required)

  • E.g. Parties on site communicate on what type, when and where activities will be performed. How they will be managed so as not to impede on other activities etc.

  • Explained work to immediately cease if activities clash and create risk to worker(s)

  • Worker tickets identified and current e.g. white card and HRWL (take image if required)

  • Contractor has SWMS for HRCW specific to their work?

  • If the contractor has their own SWMS, as the principal contractor, a pdf copy of this document should be provided to contractors conducting other type works (after the initial site induction has been completed). The contractor however, should manage their own site with traffic control etc., if independent of the principle.

  • Pdf copy of this document provided to additional contractor(s)

  • Contractor has SWPs / JSA for jobs specific to their work?

  • Contractor inducted and signed onto Council SWMS if not using their own or using both? (add detail if required)

9. Site controller e.g. supervisor / ganger instructions (if required)

    Instruction
  • Daily work Instructions provided by person in charge of site (If required)

  • Instructions

  • Date and time

  • Signature (if required)

10. Worker comments

9. Worker comments

    Comment
  • Worker comments in relation to any safety issues

  • Worker comments (add worker name if required)

  • Date and time

  • Signature (if required)

11. Permit to work (10 metre exclusion zone)

  • Permit valid to date (Insert date) (Until works completed)

  • Permit valid from (Insert date)

  • Description of work process e.g. type

  • 10 metre exclusion can be implemented? (If NO, enter reason why not)

  • Controls in place to keep unauthorised persons out of exclusion zone (Enter controls in place e.g. fencing, barriers i.e. witches hats or bunting etc., spotter(s), site induction including no go zones, visitors escorted on site etc).

  • Workers to stay well clear of mobile plant if they do not need to be in this work zone i.e. at least 10 metres

  • Discussed with workers not to walk or stand behind plant.

  • Reminded plant operators to maintain awareness of all workers working in close proximity to plant (Including attachments fully extended)

  • Discussed with workers that they must gain the attention and approval of operator before entering exclusion zone. Not to enter if they do not need to and, ensure operator has grounded all attachments before entering.

  • Discussed operator to ground equipment when idle or unauthorised persons enter zone

  • Methods of communication with workers and plant operator within exclusion zone agreed to e.g. verbal, visual, radio or hand signals (Enter type(s)).

  • Exclusion zone issue
  • Other exclusion zone issues/controls identified during works

12. TAKE 5 HIRAC

    HIRAC
  • Include steps in one assessment or, add steps separate.

  • Description of activity or task

  • Select hazard and apply a control

  • Other hazard / risk

  • Hazard Identification and Risk Rating

  • Assessed / Reported by

  • Date and time assessed / reported

  • Description of risk control

  • Action completed by

  • Date and time risk controlled

  • Take 5 is identifying any potential unforeseen hazard(s) that may pose a risk to workers. Once identified they are risk rated and then risk controlled at any stage during works. The hierarchy of control is the method used i.e. Eliminate, substitute, isolate, engineer , administration or PPE control being the lowest control measure.

13. Weekly refresher for general worksite requirements explained includes PPE requirements

    Weekly refresher
  • All staff working in an outdoor environment must wear their allocated sun protection personal protective (PPE) equipment. Council understands it is impractical to wear all PPE, such as hats, in every situation and a reasonable tolerance is provided for actions such as walking between buildings, to a vehicle etc. Otherwise all PPE must be worn. E.g. PPE - Broad brim hardhats or legionnaire style caps and Council issue sunhats

  • Select requirements identified and discussed as required.

  • Council issue hardhats and/or sunhats to be worn on site as per UVR Policy?

  • TAKE 5 Risk assessment conducted at beginning of shift, throughout day each day of work (add comments in notes if required).

  • Other identified worksite requirements (Provide detail)

Presenter comments, name and title and signature

    Presenter comments, name, title and signature
  • Summary Comments

  • Presenter Name, Title and Signature

  • Present title and permit(s)

Worker name, title and signature (All participating in toolbox talk)

    Worker
  • Worker name, title and signature

  • Worker title and permit(s)

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.