Chubb Take 5

• Inspection Date

  Date

• SCR Number where Task is to be completed

• Client Site where Task is to be completed
  Address

• Job / Task

  Do & Charge

  Instalation

  Inspection & Testing

  Other

• Technician

• UTC CARDINAL RULES I understand the UTC Cardinal Rules and understand that they are in place to protect my safety and that of my colleagues. I also understand that a breach of a Cardinal Rule may be considered serious misconduct, the penalty for which may lead up to and include dismissal, potentially ending my employment with Chubb New Zealand Ltd.

• Am I fit to preform the task (aware, rested and alert)?

  Yes

  No

• * You have selected "NO' to one of the first 5 questions. Do not proceed with work until you can answer yes by putting controls in place. If in Doubt contact your Supervisor. ***YOU ARE NOT AUTHORISED TO BEGIN WORK****

• Controls are now in place

• Have I walked through and assessed the the area before commencing the task

  Yes

  No

• * You have selected "NO' to one of the first 5 questions. Do not proceed with work until you can answer yes by putting controls in place. If in Doubt contact your Supervisor. ***YOU ARE NOT AUTHORISED TO BEGIN WORK****

• Controls are now in place

• Am I using the correct tools / PPE for the task?

  Yes

  No

• * You have selected "NO' to one of the first 5 questions. Do not proceed with work until you can answer yes by putting controls in place. If in Doubt contact your Supervisor. ***YOU ARE NOT AUTHORISED TO BEGIN WORK****

• Controls are now in place

• Have I put all SAFE Controls in Place to ensure that I dont breach a Cardinal Rule

  Yes

  No

• * You have selected "NO' to one of the first 5 questions. Do not proceed with work until you can answer yes by putting controls in place. If in Doubt contact your Supervisor. ***YOU ARE NOT AUTHORISED TO BEGIN WORK****

• Controls are now in place

• Do I know what to do in an emergency

  Yes

  No

• * You have selected "NO' to one of the first 5 questions. Do not proceed with work until you can answer yes by putting controls in place. If in Doubt contact your Supervisor. ***YOU ARE NOT AUTHORISED TO BEGIN WORK****

  Do & Charge

  Instalation

  Inspection & Testing

  Other

• Controls are now in place

• HAZARDOUS ENERGY ELECTRICAL - Do I need to isolate and test for Zero Energy State using LOTO and Volt Alert? ***For Security Systems under 50v DC ZES is not required***

  Yes

  No

• - Hazard Identified - Hazardous Electrical Energy. Scan, Assess, Fix, Execute: What effect could the hazard have on people property and the Environment

• Hazard Identified

• Controls you implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Safe to continue?

  Yes

  No

• Call your Supervisor for Assistance ***YOU ARE NOT AUTHORISED TO BEGIN WORK***

• I have called my Supervisor for advice and guidance

• HAZARDOUS ENERGY MECHANICAL - Can I be harmed by stored energy (water, gas under pressure) heat, fumes, chemicals?

  Yes

  No

• - Hazard Identified - Hazardous Mechanical Energy. Scan, Assess, Fix, Execute: What effect could the hazard have on people property and the Environment

• Hazard Identified

• Controls you implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Safe to continue?

  Yes

  No

• Call your Supervisor for Assistance ***YOU ARE NOT AUTHORISED TO BEGIN WORK***

• I have called my Supervisor for advice and guidance

• FALL PROTECTION - Can I fall from height?

  Yes

  No

• - Hazard Identified - Working at Heights. Scan, Assess, Fix, Execute: What effect could the hazard have on people property and the Environment

• Hazard Identified

• Controls you implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Safe to continue?

  Yes

  No

• Call your Supervisor for Assistance ***YOU ARE NOT AUTHORISED TO BEGIN WORK***

• I have called my Supervisor for advice and guidance

• WORKING UNDER SUSPENDED LOADS - Am I concerned that something may fall on me or strike me?

  Yes

  No

• - Hazard Identified - Suspended Loads. Scan, Assess, Fix, Execute: What effect could the hazard have on people property and the Environment

• Hazard Identified

• Controls you implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Safe to continue?

  Yes

  No

• Call your Supervisor for Assistance ***YOU ARE NOT AUTHORISED TO BEGIN WORK***

• I have called my Supervisor for advice and guidance

• Could there be uncontrolled movement?

  Yes

  No

• - Hazard Identified - Uncontrolled Movement. Scan, Assess, Fix, Execute: What effect could the hazard have on people property and the Environment

• Hazard Identified

• Controls you implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Safe to continue?

  Yes

  No

• Call your Supervisor for Assistance ***YOU ARE NOT AUTHORISED TO BEGIN WORK***

• I have called my Supervisor for advice and guidance

• GRAVITY - Can I slip or trip on anything?

  Yes

  No

• - Hazard Identified - Slips Trips and Falls. Scan, Assess, Fix, Execute: What effect could the hazard have on people property and the Environment

• Hazard Identified

• Controls you have implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Safe to continue?

  Yes

  No

• Call your Supervisor for Assistance ***YOU ARE NOT AUTHORISED TO BEGIN WORK***

• I have called my Supervisor for advice and guidance

• MANUAL HANDLING - Can I strain or over exert myself?

  Yes

  No

• - Hazard Identified - Manual Handling . Scan, Assess, Fix, Execute: What effect could the hazard have on people property and the Environment

• Hazard Identified

• Controls you have implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Safe to continue?

  Yes

  No

• Call your Supervisor for Assistance ***YOU ARE NOT AUTHORISED TO BEGIN WORK***

• I have called my Supervisor for advice and guidance

• LINE OF FIRE - Can I be caught in, on, or between anything?

  Yes

  No

• - Hazard Identified - Line of Fire. Scan, Assess, Fix, Execute: What effect could the hazard have on people property and the Environment

• Hazard Identified

• Controls you have implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Safe to continue?

  Yes

  No

• Call your Supervisor for Assistance ***YOU ARE NOT AUTHORISED TO BEGIN WORK***

• I have called my Supervisor for advice and guidance

• Can I damage any equipment?

  Yes

  No

• - Hazard Identified - Damage to Equipment. Scan, Assess, Fix, Execute: What effect could the hazard have on people property and the Environment

• Hazard Identified

• Controls you have implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Safe to continue?

  Yes

  No

• Call your Supervisor for Assistance ***YOU ARE NOT AUTHORISED TO BEGIN WORK***

• I have called my Supervisor for advice and guidance

• Do I need to communicate to my workmates the risks associated with this task?

  Yes

  No

• What Needs to Be Communicated?

• How will this be communicated?

• Safe to continue?

  Yes

  No

• Call your Supervisor for Assistance ***YOU ARE NOT AUTHORISED TO BEGIN WORK***

• I have called my Supervisor for advice and guidance

• ENVIRONMENT - Is there a chance I could spill or pollute something?

  Yes

  No

• - Hazard Identified - Environment. Scan, Assess, Fix, Execute: What effect could the hazard have on people property and the Environment

• Hazard Identified

• Controls you have implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Hazard Identified

• Controls you implemented to reduce the risk

• Safe to continue?

  Yes

  No

• Call your Supervisor for Assistance ***YOU ARE NOT AUTHORISED TO BEGIN WORK***

• I have called my Supervisor for advice and guidance

Thank you for Completing this Take 5! You can now undertake your task.

• Remember : If you work unsafely and breach a cardinal rule, losing your job is not the worst thing that can happen to you. Think about your family and work safely