Health & Safety Warning - Southern Safety SolutioNZ

• Project Name and/or Job Number

• Site Address

• Conducted on

  Date

• Business Representative

• Location
  Address

• Document No.

Worker / Contractor's Details and History

• Company Name (if applicable)

• Name

• How many H&S breaches previously?

• Is there a policy or Safe Operating Procedure/Safe Work Method Statement available for the job?

  Yes

  No

• Raise as Health and Safety matter at next meeting.

• Has the Worker been inducted and trained to this standard and training records are available?

  Yes

  No

• Attach Worker information to file

Details of WH&S Breach

• Date and time of breach

  Date

• Type of breach

  Select inadequate PPE incomplete forms / paperwork Abusive behavior Drugs / Alcohol Out of date equipment / registers Un-licensed activity Other

  • inadequate PPE
  • incomplete forms / paperwork
  • Abusive behavior
  • Drugs / Alcohol
  • Out of date equipment / registers
  • Un-licensed activity
  • Other

• State Breach

• Enter specific details of breach -

• Add any relative photos / media

  Media

Signature

• Is this the 3rd and final stike?

  Yes

  No

• I understand that this is my 3rd and final strike and under the businesses 3 strike policy I am no longer permitted to work on any of their job sites.

• Schedule Worker in for re-training and increased monitoring.

• I hereby accept that the details on this form are true and correct and will rectify my actions to conform with all procedures and policies.
  I understand that the business only allows 3 strikes before I will no longer being able to access their sites.

• Person accepting strike

  Sign

• Person filling out form and witnessing

  Sign