Title Page
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Inspection No:
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Service Site
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Conducted on
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Inspected by
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Location of activity inspected
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Select the type(s) of activity being inspected
- New product installation
- New product commissioning
- Preventive Maintenance
- Troubleshooting / Repair / Works under warranty
- Other
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Short description of activity being inspected
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Staff inspected (name & role)
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Provide pictures of the working environment(s) and product(s) being worked on
WHS Policies
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WHS Procedures
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WHS Incident, Near-Miss and Observation Reporting
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Life Saving Rules Policy
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Right to Refuse Policy
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‘Stop, Stand Back and Get Help’ Policy
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‘Take 5 ’ Policy
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Drugs, Alcohol and Smoking Policy
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Cold/Heat Stress Management
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Mobile Phone Policy
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Site Emergency Response Procedures
WHS Procedures requirements
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Job Safety Review
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Risk Control Plan
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Pre-Job Check
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Take 5 Risk Assessment
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Lockout-Tagout (LOTO)
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Customer Permit-to-Work
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Knowledge of Field Service Bulletin for product being worked on
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Knowledge of User / Service Manual(s) relevant for the activity
WHS Competencies requirements
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Qualified Electrical Worker Level
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First Aid / CPR /AED
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LoTo
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Site WHS Induction
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Hazardous Substances
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Confined Space Entry
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Working at Height
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Understanding of electrical installation/system
Electrical Safety
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Is this section fully/partially applicable?
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Barricades used to restrict access to the work area when performing work on exposed energized electrical parts?
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Competent stand-by person available during electrical work outside the barricade?
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Absence of conductive tools and equipment (incl. jewellery and other articles such as prescription eye glasses)?
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Use of calibrated voltage reading meter for determining absence of voltage?
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Any remaining live parts prevented from getting contact with?
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Pre-use check and suitable PPE worn when exposed to electrical shock ?
Fall Protection / Working at height
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Is this section fully/partially applicable?
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Hierarchy of controls applied (eliminate, prevent, minimize)?
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Fall arrest equipment used when employees are working at elevations greater than 1.8 meters?
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Pre-use checks performed on fall arrest equipment or other working at height equipment?
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Use non-conductive portable ladders?
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Fall arrest protection equipment undergoes a documented inspection at least six Monthly?
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Scaffolding being used erected for intended use, in good conditions and equipped with green tag following weekly inspection?
Lockout / Tagout
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Is this section fully/partially applicable?
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Hazardous energy physically isolated from equipment to be worked on using suitable energy isolation device?
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Locks placed by each member of the working party on each energy isolating devices (or suitable group lockout in place)?
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Locks utilized for safeguarding works are red and have only one key?
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Tag with name, contact details and ‘Do Not Operate’ text affixed to each lock?
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Stored energy release and verification steps of LoTo process suitably performed?
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Suitable process in place for lock transition?
Powered Industrial Trucks
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Is this section fully/partially applicable?
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PIT in good condition (incl. due date for inspection)?
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Pre-use inspection conducted by PIT operator?
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Restraint systems incl. seat belts utilized by PIT operator?
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Safe loading and driving practice?
Other PPE
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Suitable PPE for head and face protection?
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Suitable PPE for hand protection?
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Suitable PPE for foot protection?
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Suitable PPE for breathing protection?
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Suitable PPE for hearing protection?
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Suitable PPE for body protection?
Workplace Access and Environment
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Safe access walkway to the workplace?
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Walking and working surface in good condition at the workplace, with satisfactory housekeeping level?
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Walkways are properly separated from vehicle routes?
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Identification and warning signs used for all hazardous areas in the vicinity?
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Sufficient lighting at the workplace and for the task?
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Physical risks being controlled (noise, vibration, radiations, heat/cold…)?
Product, tools and equipment
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Product being worked on in good conditions?
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Tools and equipment (incl. leads, cables and extension cords) in good conditions?
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Tools and equipment duly inspected (incl. pre-use check)?
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Tools and equipment suitable for the task?
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Vehicle fitted with First Aid Kit and Fire Extinguisher?
Lifting, manual handling and postures
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Safe mechanical lifting technique and planning?
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Safe manual handling technique and planning?
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All staff in healthy/ergonomic posture?
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All staff in safe position (not in in hazardous location or line of fire)?
Hazardous substances and Environment
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Is this section fully/partially applicable?
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All persons that handle/use hazardous substance(s) aware about associated hazards?
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Containers of hazardous substances in good condition and labelled, without risk for soil/water contamination?
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Material Safety Data Sheet available and accurate?
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Wastes properly segregated and disposed of?
Emergency Response
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Access to relevant emergency response means (incl. phone, extinguisher and electrical rescue) and escape routes free from obstacles?
Other
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Any other unsafe situation / behaviour observed? (not falling into one of the above categories - use notes to describe)
Good Practice
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Any good practice identified? (use notes to describe)
Completion
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Inspected by
