Information

  • Client / Site

  • Prepared by

  • Conducted on

TAKE 5

  • Task To Be Completed

  • Emergency Radio Channel

CHECKLIST

  • Am I authorised to perform the job? (Trained and deemed component)

  • Am I physically able to do the task?

  • Have I read/signed off on any procedures, work instruction or JHA for the job?

  • Do I have the correct tools or equipment for the job?

  • Has a pre-start been conducted for equipment or machinery I will be using?

  • Have energy sources been identified, isolated, locked out and tagged? (Test and try)

  • Have I inspected my work area? Do I know what is going on around my job?

  • Are driving conditions safe?

  • Do I have the correct PPE for the job? Is it in good condition?

  • Have I checked that controls are in place? Are they working and effective?

HAZARD CONTROL

  • no label
  • Am I working around other people who could be affected by my task?

  • List Controls

  • Residual Risk (refer to risk matrix)

  • Have environmental conditions changed? Have they created new hazards?

  • List Controls

  • Residual Risk (refer to risk matrix)

  • Is there the chance that I could spill/pollute/damage/disturb the environment/community?

  • List Controls

  • Residual Risk (refer to risk matrix)

  • Will I be working with hazardous materials? (refer to MSDS)

  • List Controls

  • Residual Risk (refer to risk matrix)

  • Could I be struck by something or caught in, on, or between?

  • List Controls

  • Residual Risk (refer to risk matrix)

  • Is it possible to slip, trip or fall more than 1.8mtrs?

  • List Controls

  • Residual Risk (refer to risk matrix)

  • Are there any other hazards present?

  • Hazard
  • Hazard

  • List Controls

  • Residual Risk (refer to risk matrix)

PERMITS

  • NOTE: IF ANY PERMITS ARE REQUIRED, CONTACT YOUR SUPERVISOR BEFORE COMMENCING YOUR TASK.

  • Confined Space

  • Hot Works

  • Working at Heights

  • Excavation/Dig Permit

  • Vicinity/High Voltage Permit

  • Environmental/Cultural Permit

  • Other, please specify

  • Employee Signature

Take 5's to be passed onto Safety Department at the end of each shift.

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.