Title Page
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Customer:
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Project reference:
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Projectname:
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Survey done by:
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Conducted on
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Location:
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Project responsible:
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Engineer(s):
Instructions
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- Quote every point according legend
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- Note any actions to undertake, the respective responsible and the due action for action
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- If no actions: note "none"
Survey items
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1. Access procedure to work location
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2. Availibility first aid assistance and first aid material
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3. Preparation emergency situations
4. Information /Documentation present
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4.1 Health & Safety plan
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4.2 Specific site regulations
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5. Knowledge project specific risks/ rules personnel/ subcontracters
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6. Coordination: does work of other persons present any risk to Proximus staff
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7. Waste (clear arrangements)
8. Working environment
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8.1 Order & Neatness
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8.2 Sound level on/around the workplace
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8.3 Hygiene, housing, sanitary facilities
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8.4 Ergonomic conditions
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8.5 Lighting
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8.6 Temperature, weather conditions
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9. Hazards in relation to slips, trips, falls
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10. Restriction of risks in regard to traffic: Availibility of roadblocks, signalisation
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11. Working area fenced off
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12. Working on heights (+2m)
13. Material with potential risks (certificates)
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13.1 Hoisting equipment
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13.2 Electrical tools
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13.3 Ladders, stairs, elevators
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13.4 Equipment of a third party
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14. Dealing with dangerous substances
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15. Personal protection equipment
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16. Risks in relation to electricity
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17. Inconveniences due to environment
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18. Specific risks (demolition, dust, vibrations, radiation, asbestos, work near water, etc...)
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19. Has the collaborator done the LMRA/ Is he aware of the LMRA?
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20. Other risks
Name & Signature
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Signature
