Connect site specific risk assessment

• Site location
  Address

• Job identification (For example - Job number, Route ID, LMJ Number, Spine Number, Work Order Number)

• Has a stat pack been provided?

  Yes

  No

  N/A

• Work type

  Select Cabling Splicing Civils

  • Cabling
  • Splicing
  • Civils

• Environment

  Select Overhead Underground

  • Overhead
  • Underground

• Weather

  Select Sunny Raining Snowing/Sleet Windy Foggy/Misty Thunder/Lightning

  • Sunny
  • Raining
  • Snowing/Sleet
  • Windy
  • Foggy/Misty
  • Thunder/Lightning

Team Details

• PICH In House or Subcontractor

  PICH In House/Self-Employed

  Subcontractor

• Name of subcontracting company

• Lead engineer name

• Engineers on site

• I agree I have been briefed on the site and all hazards, risks and control measures

• Visitor Name

• Visitor signature

  Sign

Personal Protective Equipment (PPE)

• Personal Protective Equipment being used on site (ensure all working on site complete a pre-use visual check on all PPE)

  Select Hi-Visibility Clothing Safety Boots Safety Helmet Waterproof Clothing Safety Goggles/Glasses Ear Defenders- as site noise will exceed 80dB(A) Respiratory Protective Equipment (RPE) Dust Mask Fall Restraint Harness Fall Arrest Harness Lanyard Work Belt Other

  • Hi-Visibility Clothing
  • Safety Boots
  • Safety Helmet
  • Waterproof Clothing
  • Safety Goggles/Glasses
  • Ear Defenders- as site noise will exceed 80dB(A)
  • Respiratory Protective Equipment (RPE)
  • Dust Mask
  • Fall Restraint Harness
  • Fall Arrest Harness
  • Lanyard
  • Work Belt
  • Other

• Please provide details

Gas Detection Unit

• GDU result

  Select Negative Result - No Alarm Positive Result - Alarm Sounded Not Required - Work at Height/Surveying

  • Negative Result - No Alarm
  • Positive Result - Alarm Sounded
  • Not Required - Work at Height/Surveying

• DO NOT COMMENCE WORKS. Contact a site supervisor for next steps.

CAT and Genny

• Has a CAT and Genny been used?

  Yes

  No

  N/A

Location of Welfare

• Provide the location of the nearest welfare facilities (This includes - toilets, food, drink and handwashing)
  Address

Fire Assembly Point

• Please detail a fire assembly point (this is the location the team can evacuate to in the event of a fire on site).
  Address

Tooling and Equipment

• Has a pre-use visual check been completed on all tooling and equipment that will be used on site?

  Yes

  No

• Persons at risk from on site hazards

  Select Workforce Visitors Members of the public Other Contractors

  • Workforce
  • Visitors
  • Members of the public
  • Other Contractors

Hazards & Risk Scoring

• Answer yes or no to the occurrence of each of the hazards listed.
  Where the answer is yes, please review the relevant task based risk assessments. All task based risk assessments can be found using the dropbox QR code and web link at the end of this template. Please Detail any additional controls that you may require on site that ARE NOT included on the task based risk assessment (this includes any site specific controls that are not standard practice for the task). Using the table attached, score the level of risk considering the controls you have implemented (low, medium or high) for each hazard. Where 1 or more hazards that remain high risk, works should be stopped and a manager must be contacted.

  

• The Environment

  Yes

  No

• Please detail any controls required that are ADDITIONAL to the task based risk assessment listed, or any site specific controls.

• Level of risk (Likelihood x Severity)

  Low

  Medium

  High

• Traffic and Vehicles

  Yes

  No

  N/A

• Please detail any controls required that are ADDITIONAL to the task based risk assessment listed, or any site specific controls.

• Level of risk (Likelihood x Severity)

  Low

  Medium

  High

• Handling and Lifting

  Yes

  No

  N/A

• Please detail any controls required that are ADDITIONAL to the task based risk assessment listed, or any site specific controls.

• Level of risk (Likelihood x Severity)

  Low

  Medium

  High

• Working Underground

  Yes

  No

  N/A

• Please detail any controls required that are ADDITIONAL to the task based risk assessment listed, or any site specific controls.

• Level of risk (Likelihood x Severity)

  Low

  Medium

  High

• Working Overhead

  Yes

  No

  N/A

• Please detail any controls required that are ADDITIONAL to the task based risk assessment listed, or any site specific controls.

• Level of risk (Likelihood x Severity)

  Low

  Medium

  High

• Work tools and equipment

  Yes

  No

  N/A

• Please detail any controls required that are ADDITIONAL to the task based risk assessment listed, or any site specific controls.

• Level of risk (Likelihood x Severity)

  Low

  Medium

  High

• Please detail any additional hazards, controls or safe systems of work that have NOT been included above

• Are civils works being completed?

  Yes

  No

  N/A

• Do you have symptoms of exposure to vibration?

  Select No Yes - Numbness or tingling of fingers lasting more than 20 minutes after using vibrating equipment Yes - General numbness or tingling of fingers, hands, or wrists Yes - A defined whiteness in your fingers followed by a red flush, on exposure to cold Yes - Difficulty picking up small objects

  • No
  • Yes - Numbness or tingling of fingers lasting more than 20 minutes after using vibrating equipment
  • Yes - General numbness or tingling of fingers, hands, or wrists
  • Yes - A defined whiteness in your fingers followed by a red flush, on exposure to cold
  • Yes - Difficulty picking up small objects

• Hand Arm Vibration Exposure Calculation

  

• Hand Arm Vibration Table

  

• Total Exposure Points

  Less than 100 points = Low

  100-399 points = Medium

  400 points or above = High

• Are you completing work in confined sapces?

  Yes

  No

  N/A

• Please complete the confined space entry permit on iAuditor before works begin. The confined space rescue plan can be located on dropbox using the QR code and web link at the end of this template.

• Are you completing work at height?

  Yes

  No

  N/A

• Access method

  Ladder

  MEWP

• Have you completed a pre-use check on this ladder that deemed it safe to use?

  Yes

  No

  N/A

• Has a pre-climb check been completed? (Use the pre-climb checklist in the document section of this template)

  Yes

  No

  N/A

• Which fall protection system has been selected? (ensure to complete a pre-use visual check on all fall protection items - harnesses, lanyards and work belts)

  Select Fall Restraint - Typically used for working on MEWP's Fall Arrest - Typically used for working on ladders

  • Fall Restraint - Typically used for working on MEWP's
  • Fall Arrest - Typically used for working on ladders

• The work at height RAMS and rescue plans can be located on dropbox using the QR code and web link at the end of this template.

• This site-specific risk assessment is an accurate reflection of the work site and I agree to update this form as and when conditions on site change. I will ensure all control measures listed are in place at all times. Where a hazard becomes high risk, I will stop works.

• Lead Engineer Signature

  Sign

• Engineer Signature

  Sign

• Engineer Signature

  Sign

• Engineer Signature

  Sign

• Engineer Signature

  Sign

• Engineer Signature

  Sign

• For all PICH Group Ltd Health and Safety documents scan the QR code below or use this link https://www.dropbox.com/scl/fo/oitgs7ukwlt4mcyc0krsb/h?dl=0&rlkey=o79bk8k9p1783s0iqc5lvahvw

  

• A1024 Phone Number (to report damage, defects or safety issues to BT infrastructure) - 0800 023 2023

• Pole Pre Climb Checklist

• NOTE- Pole steps must ONLY be removed/installed by qualified operatives!

• Connect Welfare Risk Assessment