Daily Pre-start JSEA Form (with Site Layout Plan)

• Date:

  Date

• Project:

• Client / Site

• Location
  Address

• Prepared by

• Personnel

• First Aider/s:

• Emergency Evacuation Point:

• Nearest Medical Facility / Hospital:

• Emergency Equipment Location:

• Site Specific Personal Protective Equipment (PPE) Required

  Select Hard Hat Hearing Protection Gloves Steel cap boots Hi--Vis vest Safety Glasses Respiratory aid Full Length shirts/pants

  • Hard Hat
  • Hearing Protection
  • Gloves
  • Steel cap boots
  • Hi--Vis vest
  • Safety Glasses
  • Respiratory aid
  • Full Length shirts/pants

• Additional PPE:

Permits and Plans

• Confined Space Entry

• Working at Height

• Excavation and Drill

• Isolation

• Hot Work

• Environmental / Land Access

• Workbox

• Other:

Plant and Equipment

• Pre-start inspection completed on plant?

  Yes

  No

  N/A

• Lifting gear inspected and tagged?

  Yes

  No

  N/A

• Electrical gear tested and tagged?

  Yes

  No

  N/A

• Plant risk assessed, inducted, and accepted?

  Yes

  No

  N/A

• Climbing equipment (including ladders) inspected?

  Yes

  No

  N/A

• Fall arrest equipment inspected?

  Yes

  No

  N/A

• Safety detection (E.G Radman) equipment operational/calibrated?

  Yes

  No

  N/A

• Other:

• Other:

What are the tasks we are doing today?

• 1.

• 2.

• 3.

• 4.

• 5.

Hazards

Add a Hazard:

• What are the key risk controls to be implemented?

• What are the key hazards?

• Who is responsible?

• Critical Risk?

  Yes

  No

• Note SHEWMS reference no.

Other considerations:

• Are there any other factors that can affect your work area (i.e. other work crews)? [Note Below]

  Yes

  No
Please list:

Competencies required to complete task (including verification of competency)

Add Competencies

• Name:

• Competency:

• Ticket number:

• VOC Required?

  Yes

  No

• Upload evidence

  Media

• Are there any incidents, injury concerns, hazard alerts, SHEQ alerts, directives, positive events/news, etc. that require discussing?

  Yes

  No
Add comment

Specific Topics/issues raised:

Add topic/issue:

• Topic / Issue:

• Comment or Action:

Emergency Plans:

• Emergency response plans communicated and well understood by all workers onsite?

  Yes

  No

Induction / Onboarding / Training / Competency:

• All workers have been on-boarded/inducted appropriately and are trained and competent to complete all tasks?

  Yes

  No

Changes to design/plans:

• Have changes to approved design / construction plans been assessed for risk and communicated to workers?

  Yes

  No

  N/A

Weather forecast:

• Morning:

• Afternoon:

Complete Site Layout Plans

• Draw site plan into Site Layout Plan. If modifications are required to plan, use Site Layout Plan 2 and so on. Insert the following:
  • Parked vehicles, operating vehicles and plant
  • Planned vehicle and plant movement
  • Work areas and roads
  • Pedestrian and worker movement/pathways
  • Exclusion zones and barriers
  • Evacuation/muster point
  • Emergency equipment including rescue kits, spill kits, first aid kits, etc.
  • Waste recycling points, etc.
  • Potholes, manholes, utility services, etc.
  • Site sheds or offices, etc.
  • Nominated smoking area (must be outside the compound)
  
  Note: No smoking on high fire risk sites.

Add Site Layout Plan

• Draw Site Layout Plan

  Drawing

• Select date

  Date

• Developed by:

Pre-start Sign on

• I, the undersigned, hereby certify that I have been inducted to this job site by Visionstream or Site Supervisor, and that I have actively participated in the identification of hazards, assessment and control of risks associated with working at this location by way of this pre-start briefing. I agree to implement the control measures identified, including the use of the appropriate PPE:

Add person:

• Name and Signature:

  Sign

• Company:

• Phone number:

• Start:

  Date

• Finish:

  Date

Authorising signature

• I certify that this form was completed prior to commencing work on this site, and that all workers and visitors have been inducted to site:

• Name and signature:

  Sign

• Position:

• Date:

  Date