Title Page
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Program Name
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Reason for visit
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Conducted on
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Prepared by
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Location
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Personnel
Pre-site checks
Pre-site checks
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Have you arranged the visit as per established protocols and notified others
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Have you checked the CRIP rating - if the property is tenanted
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Have you completed a SWP if needed<br>
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Have you checked the property/surrounds risk information
Self Assessment
Self assessment and Situational Awareness
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Is my Secure Locate activated
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Is it safe to exit my vehicle
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Is the site secure and safe to enter
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Am I wearing the correct PPE
Site Assessment - Part 1
Site Assessment
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Is access control effective, no unauthorised access
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Has the Hazard/Risk Register board been updated today
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Is the Hazard/Risk Register board in place
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Record: If personnel on site to see if they are aware of risks on risk register
record and compliment if induction or verbal communication of risks -
Are the PPE requirements displayed
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Is signage in place and appropriate for risk (e.g. report to site office, no entry, asbestos, danger)
Site Assessment - Part 2
Site Assessment Optional Section depending on activities on site/to be targeted
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PPE and manual handling Section
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Are all workers wearing correct PPE
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Are acceptable manual handling methods being used for tasks observed
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Working at Height Section
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Has the most appropriate equipment been chosen for work at height e.g. scaffolding, mobile scaffolding, elevated platform, ladder
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If work is being conducted within 4m of overhead power lines is effective isolation in place (e.g. power disconnection, sleeving, or close approach consent).
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Scaffolding Section
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Is the tag valid (present, weekly inspection recorded, completed in full)
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If the scaffolding exceeds 5m in height has WorkSafe been notified (does not apply if single storey home)<br>
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If the scaffolding exceeds 5m in height has it been erected by a holder of a current certificate of competence
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Is scaffolding installed to standard (e.g. soleboards 500mm x 200mm x 38mm thick, base boards, platforms, toe boards, stabilising legs, stand offs, gates, ladder attachments, edge protection installed effectively)
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Ladders Section
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Is the ladder set up at 1:4 ratio (1m horizontal to 4m vertical)
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Can users maintain 3 points of contact at all times
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Is the ladder secured at top and base to prevent slipping sideways/out
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Do all ladders have more than 3 steps
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Power Supply Section
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Are safety devices in place
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If power isolated is a lock out device in place with tag
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Have power source (e.g. distribution box) leads been tagged
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Are tags valid and leads in good working order
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Are leads used in a safe manner
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Tools & Machinery Section
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Are power tool tags valid
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Are safety devices operable i.e. not tampered with
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Are the right tools or machinery being used for the job
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Are all dangerous parts guarded
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Do all tools and machinery appear to be in good working order
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Hazardous Substances Section
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Is dust control in place at source for respirable dust and/or paint particles e.g. timber, silica, lead based paint
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Is waste from any dust extraction system disposed of safely
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Is correct PPE for cutting activities worn (e.g. ear protection, eye protection, P2 dust mask)
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Are lead test results on site
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Are lead containment controls sufficient and in good condition (e.g. plastic sheeting ground cover, sealed openings) <br>
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Is HNZ permitted method used for lead based paint removal (chemical stripping, wet scraping, wet hand sanding) <br>
Summary
Actions completed at site
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Positive Observation
- Opportunity for Improvement Corrective Action General Comments