Title Page

  • Conducted on

  • Prepared by

  • Location
  • Date:

  • Time:

  • Audited by:

  • Address:
  • Description of Works:

  • Name of Contractor:

  • Name of Supervisor:

  • Names of Team Members:

  • Worksite Information

  • Vehicle Rego:

  • Photo of License Plate

  • LICENCES AND QUALIFICATIONS FOR THE WORK TASK BEING COMPLETED AND ADHEARANCE TO REGULATIONS

  • Do all team members ave appropriate driving licences, (visual check)?

  • Photo of relevant drivers license

  • ESI level 2 / Limits of approach

  • Are Safe Approach Distances being adhered to in accordance with Electrical Safety Rules for the Vesi distribution network?

  • Traffic Management

  • High Risk elevated work platform licence

  • Are all staff included on contractors training Matrix? (Council officer to cross reference training matrix)

  • Are training units appropriate for work Role ? (Council officer to cross reference training matrix)

  • PERSONAL PROTECTIVE EQUIPMENT

  • Is SunSmart Workwear being worn by all team members?

  • Is safety footwear being worn by all team members?

  • Are safety vest worn by all team members and are they VicRoads approved if working on a declared road?

  • Is earing protection being worn? (if required)

  • Is eye protection being worn? (if required)

  • Is head protection being worn? (if required)

  • Is hand protection being worn? (if required)

  • Are chainsaw pants or chaps being worn where required?

  • Where applicable is additional PPE being worn appropriate to the task?

  • SITE SET UP including TRAFFIC & PEDESTRIAN MANAGEMENT

  • Is suitable traffic and pedestrian management being used for te site?

  • Are the signs in use suitable for the task and in good condition?

  • Are all fuel and cemical containers labelled & stored appropriately?

  • Has the Pre-start / Log Book entry been completed? (spot check two items)

  • Are audible and visible warning devices operational?

  • Does the plant/equipment have appropriate decals (i.e. CoC logo and fleet number)

  • Are all onsite veicles/plant registered?

  • Is the vehicle clean and presentable inside and out?

  • Is there any visible damage to to vehicle (both inside and out)?

  • Are seat belts worn wilst operating ride on equipment?

  • Has an onsite risk assessment / hazard assessment checklist been completed?

  • Has a Job Safety Analysis (or similar), been completed for the task?

  • Is the worksite free from trip hazards?

  • EMERGENCY RESPONSE Is a phone available ?

  • Is there a first aid kit available? When was it last replenished?

  • Is there a trained first aider on site?

  • Are fire extinguisers available? (were required)

  • Auditor Signature:

  • Team Rep/Contractor Signature:

  • Item No

  • Action Item

  • Responsible Officer (responsible for close out actions)

  • Close Out Date

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.