Title Page
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Name
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Conducted on
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Job Site ID
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Service Appt # (SA-#)
Stop Take 5 (A no answer means do not proceed)
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1. Do you have AUTHORIZATION to start the work activity? Is the work scope/safe working procedure available and fully understood by all? Are all the tools and spare parts available?
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2. Are you COMPETENT and SKILLED to do the job?Is everyone trained and competent to conduct this task as required? Does everyone all have the right qualifications and evidence to prove competence?
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3. Are you properly EQUIPPED for the work?Are the tools calibrated and suitable for the job? Are the resources (equipment, PPE and personnel) available?
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4. Are the HAZARDS around you controlled?Is anything a surprise ? Are all the hazards identified listed and able to be controlled? Are all persons (e.g. contractors, client employees, others etc.) protected from our activities in the area? Do you and the team know what to do in case of an emergency? Do you have safe access/egress to and from the work area? Is the work area clean and free of trip hazards?
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5.Are you OK to start the activity? Can you and the team do the job as planned? All controls are in place? All those potentially affected are aware of the work activities?
SPECIAL ATTENTION - Special Attention should be paid to the following hazards.
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Step 4 of the 7 Steps. I will verify the absence of voltage prior to starting work. MISSING THIS STEP COULD END YOUR LIFE.
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Cut Prevention. I have reviewed the cut risks associated with this job.
Site Specific Risks (List Hazard and controls in place to address the hazard)
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Site Hazard #1
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Site Hazard #2
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Site Hazard #3
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Site Hazard #4
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Site Hazard #5
ALL CLEAR -- PICW confirms controls are in place to maintain risk levels at a "low" and the controls have been explained to all members of the working party.
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PICW
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Signature of person #2
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Signature of person #3
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Signature of person #4
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Signature of person $#5
