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

• Air lock and enclosure present, intact, clean, dry and suitable for the work?

  Yes

  No

  N/A

• Smoke test carried out and report provided?

  Yes

  No

  N/A

• Smoke test (Record date and report number if applicable)

  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

• Air mover (NPU) present, operational and suitable for the work?

  Yes

  No

  N/A

• 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 and clearance.

  Media

• Stage 1 Preinspection Result

  PASS

  FAIL

Stage 2 - Visual Inspection

• Enclosure Details (HxWxD)
  

  

• All areas accessed?

  Yes

  No

• Exclusions

  Yes

  No

• Asbestos containing materials have been removed

  Yes

  No

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

  PASS

  FAIL

• Photo representative of the removal work area

  Media

• Comments

• Stage 2 Visual Result

  PASS

  FAIL

Stage 3 - Air Monitoring and Dust Sampling

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

  Yes

  No

  N/A

• Negative Air Unit off and sealed?

  Yes

  No

  N/A

• Air disturbance carried out?

  Yes

  No

  N/A

• Duration of air disturbance (Number of minutes)

• Number of pumps required?

• The air monitoring result was satisfactory?

  Yes - Did not exceed 0.01 f/l

  No - greater than 0.01 f/l

  Results not available at this time

• Report number:

• Surface wipes collected?

  Yes

  No

  N/A

• Number of wipes collected?

• The surface wipes result(s) was satisfactory?

  Yes - NAD

  No - Asbestos has been detected

• Report number:

• Exclusions (Areas excluded from clearance)

• Can the enclosure be dismantled?

  Yes

  No

  N/A

• Stage 3 Air Monitoring and Dust Sampling Result

  PASS

  FAIL

Stage 4 - Final Assessment

• Stage 4 (28.4.4)
  When the enclosure or work area has passed the visual inspection and / or air monitoring, and any surface wipes, the Licensed Asbestos Removalist can dismantle the enclosure.

• Stage 4 Assessment

  Date

• The area in which the enclosure was erected, the removal work zone, the area immediately surrounding the area where the enclosure was erected, and waste transit route was inspected and no visible asbestos or dust and debris was found.

  Yes

  No

• No asbestos debris was present around the waste container / vehicle?

  Yes

  No

  N/A

• 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