Clearance Report

• Prepared by

• Prepared for

• Report Number

• Completed on

  Date

• Date and Time of Assessment:

  Date

• Report to:

• Client - Company and Person

Removal Details

• Removal Company Name

• Licensed Asbestos Removalist Supervisor (Record Licence number if applicable)

• Removalist Contact Name

• Removal Site Address:
  Address

• Site Details (Building/Level/Floor/Unit)

• Scope of Works:

  Class A

  Class B

• Removal details (eg textured ceiling scrape)

• Dates the removal work was carried out

• Did you sight a copy of the Worksafe Notification?

  Yes

  No

  NA

• Did you sight copy of of the Safe Work Method Statement (SWMS)?

  Yes

  No

  N/A

• Are works consistent with control plan?

  Yes

  No

  N/A

• Is the Asbestos related/ removal works consistent with WorkSafe Notification, SMMS and Removal Plan?

  Yes

  No

  N/A

• Comments

Stage 1 - Preliminary Site Inspection

• Appropriate signage and exclusion zones established?

  Yes

  No

  N/A

• Adequate equipment for inspection / removal?

  Select NPU Ladders Scaffold Adequate lighting Waste disposal Signage appropriate H-type Vacuum PPE adequate Background monitoring

  • NPU
  • Ladders
  • Scaffold
  • Adequate lighting
  • Waste disposal
  • Signage appropriate
  • H-type Vacuum
  • PPE adequate
  • Background monitoring

• Decontamination facilities provided and operational?

  Yes

  No

  N/A

• The area surrounding the removal zone and waste transit route was inspected and no visible asbestos or dust and debris was found.

  Yes

  No

  N/A

• Photo representative of the works area and set up

  Media

• Stage 1 Preinspection Result

  PASS

  FAIL

Stage 2 - Visual Inspection

• All areas accessed?

  Yes

  No

• Exclusions

  Yes

  No

• Asbestos containing materials have been removed

  Yes

  No

• The area immediately within the removal zone inspection area and the area immediately surrounding the removal zone was inspected and no visible asbestos or dust and debris was found.

  PASS

  FAIL

• Photo representative of the removal work

  Media

• Comments

• Stage 2 Visual Result

  PASS

  FAIL

Stage 3 - Air Monitoring and Sampling

• Air monitoring was carried out as part of the clearance inspection?

  Yes

  No

  N/A

• Samples collected?

  Yes

  No

  N/A

• Report number:

• Stage 3 Air Monitoring and Dust Sampling Result

  PASS

  FAIL

Stage 4 - Final Assessment

• Stage 4 Assessment - Not required

  Date

• Photo representative of inspection areas

  Media

• Stage 4 Final Assessment Result

  PASS

  FAIL

CLEARANCE DECLARATION

• CAN THE AREA BE REOCCUPIED?

  Yes

  No

• I the Assessor declare that:

• I found no visible Asbestos residue from asbestos removal work in the area, or in the vicinity of the area, where the work was carried out; and

  Yes

  No

  N/A

• (If air monitoring was conducted as part of the clearance inspection), the monitoring shows the respirable fibre level does not exceed 0.01 fibres/ml; and

  Yes

  No

  N/A

• As far as can be determined from the clearance inspection, the asbestos removal area does not pose a risk to health and safety from exposure to asbestos.

  Yes

  No

  N/A

• Name of a Licenced Assessor and Assessor License Number

• Select date

  Date

• Assessor

  Sign

• Removalist/ Supervisor

  Sign

• Select date

  Date

• Assessor

  Sign

• Removalist/ Supervisor

  Sign