Title Page

  • Street Name/Location
  • RCA CAR/WAP Number

  • Attended/Unattended

  • Principal

  • Employer of Site STMS

  • Date/Time

  • Rating A=Acceptable NI = Needs Improvement D= Dangerous

Responsible Party

  • STMS/TC Attended at Site?

  • Name

  • Registration Number:

  • Action Needed


  • On Site?

  • Appropriate To Situation?

  • Action Needed

High-Visibility Garments

  • Worn By All?

  • Done Up?

  • Condition Acceptable?

  • Action Needed


  • All Necessary Signs Present?

  • Correct Positions?

  • Sand Bagged For Expected Wind?

  • Conflicting Signs Covered?

  • Signs In Good Condition?

  • Action Needed


  • Protects Working Space/Other Features?

  • Longitudinal Safety Zone Appropriate?

  • Lateral Safety Zone Appropriate?

  • Taper Lengths Compliant?

  • Correct Spacing Of Cones?

  • Sufficient Positive Traffic Control?

  • Action Needed

Pedestrian Needs

  • Footpath Widths Ok?

  • Safe Passage For Pedestrians?

  • Surfaces/Ramps OK?

  • Action Needed

Cyclist Needs

  • Cycle Widths Ok?

  • Safe Passage For Cyclists?

  • Surfaces OK?

  • Action Needed

Traffic Needs

  • Lane Widths Ok?

  • Speed Limit Appropriate?

  • No Significant Delays?

  • Surfaces OK?

  • Action Needed

Property Access

  • Property Access OK?

  • Action Needed

Action Agreed By STMS/TC

  • Actions Agreed

  • HDC Auditor Name

  • HDC Auditor STMS Number

  • HDC Auditor Signature

  • STMS/TC Signature

  • Pictures Of Site

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