City West Water - Company Safety Health Check Template

• Audit Title

• Client / Site

• Site Foreman:

• Health and Safety Representative:

• Conducted on

  Date

• Prepared by

• Personnel

• Location
  Address

Roles and Responsibilities

• Are the Roles and Responsibilities defined?

  Yes

  No

  N/A

• If there are actions required, set a response rating for them? (1 = Immediate, 2 = Within 24 Hours, 3 = Within 7 Days)

  1

  2

  3

• Are these actions complete?

  Complete

  Pending

  See Comments

• Comments

Reporting and Investigating Accidents, Injuries, Incidents and Near-Misses

• Does adequate evidence exist to prove that Reporting and Investigating Accidents, Injuries, Incidents and Near-misses is taking place at this organisation?

  Yes

  No

  N/A

• If there are actions required, set a response rating for them? (1 = Immediate, 2 = Within 24 Hours, 3 = Within 7 Days)

  1

  2

  3

• Are these actions complete?

  Complete

  Pending

  See Comments

• Comments

Organisational Chart

• Does an accurate Organisational Chart exist?

  Yes

  No

  N/A

• If there are actions required, set a response rating for them? (1 = Immediate, 2 = Within 24 Hours, 3 = Within 7 Days)

  1

  2

  3

• Are these actions complete?

  Complete

  Pending

  See Comments

• Comments

Return to Work Co-Ordinator

• Does an adequate Return to Work Co-Ordinator exist?

  Yes

  No

  N/A

• If there are actions required, set a response rating for them? (1 = Immediate, 2 = Within 24 Hours, 3 = Within 7 Days)

  1

  2

  3

• Are these actions complete?

  Complete

  Pending

  See Comments

• Comments

SWMS

• Are SWMS being adequately completed?

  Yes

  No

  N/A