Title Page

  • At Maxima Training Group (Aust) Ltd, our job is to make sure the workplaces where we place our workers are safe prior to placement and they remain safe during the assignment. To achieve this, in consultation with you, the host employer, we are required to evaluate your systematic approach to managing Work Health and Safety which in turn allows us to make the safest decision about supply. This profile is designed to give us an overview of your safety systems. Once you have completed this and arrangements to supply are confirmed, we may need to verify your systems with a workplace site inspection (risk assessment). By proactively working together, we effectively are managing hazards and reducing the likelihood of illness and injury.

  • Host business name:

  • Host ABN:

  • Workplace location:

  • Date completed:

  • Worker's job title/s:

  • Assessment completed by:

  • Assessor's job title:

  • Preferred contact details (please list your phone number or email address):

  • Maxima consultant's name:

Instructions for Self-Assessment Completion

  • A representative of the Host Employer is to complete each section of the self-assessment prior to placement of Maxima worker.

    To successfully complete this self-assessment, you must:
    1. Either possess an in-depth knowledge of the role and tasks to be completed by the Maxima worker or complete this self-assessment in consultation with an employee that does (i.e. The Supervisor of the Maxima worker).
    2. Consider the hazards involved with completing each job task and visually inspecting their controls.
    3. Provide evidence of your health and safety management system, including control implementation, where possible, photographic evidence is best or alternatively relevant documentation (i.e. Standard Operating Procedures / SWMS, Completed workplace induction, SDS's, etc) can be emailed to WHSAction@Maxima.com.au along with this completed self-assessment.
    4. Physically inspect the workplace for any additional hazards, visually confirming that the amenities provided are clean and adequate and all basic safety systems (i.e. evacuation plans, first aid facilities, fire extinguisher test tag) are in working order and readily available.
    5. Provide photographic evidence of amenities (Sections 2.1 & 2.2).
    6. Add any additional relevant details in the "Note" section.
    7. Complete the Host Declaration, sign and date this assessment, check that all mandatory items have been completed, and then mark the assessment as complete.
    10. Download the pdf version of the this completed self-assessment and email it to WHSAction@maxima.com.au for review.

  • PLEASE NOTE: Any answers in red text or are followed by an orange exclamation image (as per below) will require further information, justification and evidence to be included and or may trigger a workplace inspection.

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Tips on Use

  • - You can complete one profile for multiple roles, however, you must create a new Section 3.1 for each role separately.
    - You can add additional details in the "Note" section to accurately describe the workplace, job task or provide extra context to an answer.
    - Profiles can be completed offline (i.e. in airplane mode), however, you must sign in before you can access the templates.
    - Instructions on how to export this Profile can be found here: https://support.safetyculture.com/reports/export-inspection-reports-to-pdf-and-word/

Privacy & Information Collection Notice

  • All documents, pictures, evidence provided are kept in a secure location and are only accessible by select employees of Maxima Group. Your information will not be given to any other person or agency unless you have given us permission or we are required to by law.

1. Host Work Health and Safety Systems

  • 1.1 Does your organisation have a structured and documented safety management system containing policies and procedures?

1.2 Safety Management System Evidence

  • Confirm that the safety management system has the following elements and provide photo evidence of its implementation

  • 1.2.1 Written Health and Safety Policy:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

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  • Please describe why this is not applicable:

  • 1.2.2 Consultation with Maxima's workers: (select all that apply and provide evidence)

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

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  • Please describe other methods for consulting with workers:

  • Provide evidence of implemented consultation process:

  • 1.2.3 Recorded, investigated and actioned incidents and hazards: (select all that apply and provide evidence)

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

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  • Provide evidence of implemented hazard and incident reporting and investigation process:

  • Please describe:

  • 1.2.4 Risk Assessments: (select all that apply and provide evidence)

  • Please describe:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

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  • Provide evidence of implemented risk management process:

  • 1.2.5 Provide evidence of the site induction content:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

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  • Please describe why this is not applicable:

  • A Maxima WHS Consultant may be in contact to discuss the your safety management system and arrange a workplace inspection and risk assessment.

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1.3 Safety Roles / Rehabilitation Return to Work Coordinator

  • Please list the Name/s, Position/s and Contact Details (phone and or email) of the following:

  • 1.3.1 Return to Work Coordinator (Name/s, Position/s, Contact/s):

  • 1.3.2 Safety Officer (Name/s, Position/s, Contact/s):

2. Work Environment

2.1 Amenities

  • Provide photo evidence of the following amenities to show they are readily available to Maxima's worker/s and are provided in a safe, accessible and clean manner.

  • 2.1.1 Hand washing facilities

  • Please advise why this is not available or applicable:

  • 2.1.2 Toilets with adequate facilities, privacy and security

  • Please advise why this is not available or applicable:

  • 2.1.3 Filtered and / or cool drinking water

  • Please advise why this is not available or applicable:

  • 2.1.4 Eating facilities and appropriate areas to consume food (i.e. out of the sun)

  • Please advise why this is not available or applicable:

  • 2.1.5 Storage for personal belongings

  • Please advise why this is not available or applicable:

  • 2.1.6 The workplace (building, depot or vehicle) is kept: (select all that apply)

  • Provide photo evidence of workplace / workstation:

2.2 Emergency Response

  • 2.2.1 The first aid facilities available are:

  • Additional first aid facilities available:

  • Provide photographic evidence of the first aid kit being checked / items are in date.

  • Briefly describe what is in a poor condition / out of date or not available and raise action as required:

  • Please describe why this is not applicable:

  • Appendix C of the First Aid in the Workplace Code of Practice outlines recommended first aid requirements, with the minimum for low risk workplaces being: 1 First Aider for every 50 workers, a basic first aid kit and a first aid room where there are 200 workers or more. Please note that a vehicle is considered a workplace when being driven for work purposes. https://www.safeworkaustralia.gov.au/system/files/documents/1908/code_of_practice_-_first_aid_in_the_workplace_0_0.pdf

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  • Provide photographic evidence:

  • 2.2.2 The fire fighting equipment available are:

  • Briefly describe what is in a poor condition / out of date or not available and raise action as required:

  • Provide photographic evidence of equipment having been tested (i.e. extinguisher test tag, maintenance schedule) / what is available:

  • Briefly describe what additional equipment is available

  • 2.2.3 The emergency response facilities available are:

  • Additional emergency response equipment available:

  • Emergency plans and procedures relevant to the workplace must be implemented and tested at regular intervals for every workplace. Please note that a vehicle is considered a workplace when driven for work purposes.

    Hazard Picture.JPG
  • Briefly describe what is in a poor condition / out of date or not available and raise action as required:

  • Please describe why this is not applicable:

  • Emergency plans and procedures relevant to the workplace must be implemented and tested at regular intervals for every workplace. Please note that a vehicle is considered a workplace when driven for work purposes.

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  • 2.2.4 Are emergency exits / routes free of obstructions?

  • Immediately rectify or raise action if cannot be completed during the assessment.

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2.3 Incidents and Injuries

  • 2.3.1 What is the most most common cause/s of injuries and/or incidents in the workplace:

Additional Comments:

  • Add additional comments here:

3. The Work

    3.1 The Work

When completing this profile for more than 1 position, a separate "3.1 The Work" section must be completed for each job title.

  • Job Title (only 1 can be listed in each section):

  • 3.2 Select the Work Activity:

  • 3.3 Summary of job tasks:

  • 3.4 Equipment, tools and plant to be used (Please list or provide a photo of all plant/equipment/machinery/tools to be used):

  • Please describe:

  • Please describe or provide a photo of the equipment above:

  • 3.4.2 Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Please describe or provide a photo of the equipment above:

  • 3.4.2 List any controls in place to avoid injury (i.e. Warning label on hot areas, written work instruction, etc):

  • Select the controls in place for motor vehicle use:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • 3.5 Substances, chemicals and materials to be used:

  • Attach photos above of:
    1. The substances / chemicals or materials present in their storage area; and
    2. Any spill containment kits
    3. Safety Data Sheet location

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • 3.6 Work Arrangements:

  • 3.7 Shift Start Time/s - Finish Time/s: Break Time/s or break duration:

  • 3.8 Who will directly oversee the safety of our workers day-to-day? (Please list the name and contact details of all Supervisors)

  • 3.9 Level of supervision to be provided:

  • 3.10 Training provided by your organisation before commencing work:

  • 3.10.1 Provide evidence of all applicable safe work procedures:

  • 3.11 If personal protective equipment is required, who will provide it?

  • Please describe who will provide what:

  • 3.12 What experience or qualifications are required to perform this work?

  • Please describe:

  • 3.13 Will your organisation arrange and or provide pre-employment screening, functional capacity or health monitoring? (i.e. pre–employment medical, hearing tests, drug & alcohol testing)

  • 3.13.1 Please describe what screening or monitoring will be provided by your organisation for Maxima worker/s:

  • Please describe:

  • 3.13.1 Do you require Maxima to arrange any pre-employment screening / medical prior to commencement? (Please list any special requirements (i.e. sleep test, full physical capabilities test, etc) in the "Note" section below.

4. Hazards in the workplace

  • Will the Job/Task require our worker to undertake or be exposed to any of the following? (select all that apply):

  • Biological materials (human waste, needle stick injury, blood, etc)

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Confined Spaces

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Conveyor belt use

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Electricity or electrical shock hazards

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Falling objects

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Fast pace

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Fatigue

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Hazardous manual tasks (i.e. computer work)

  • Select how the hazard could occur:

  • Please describe:

  • Select the controls in place:

  • Please describe:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Hot / cold work environments (i.e. cold air conditioning, near heat generating equipment)

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Loud noise levels which exceed the regulated standard in the general work environment (i.e. large crowd in a hall, using a phone headset, etc)

  • Select the controls in place and provide photographic evidence:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Multiple PCBU's / businesses operating in the same work area

  • Select the controls in place:

  • Other controls in place are:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • On or near water

  • Select the controls in place:

  • Other controls in place are:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Personal threat / duress (i.e. interacting with members of the public either face-to-face or on the phone)

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Pinch points

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Poor lighting / glare

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Remote or Isolated (being alone – work, travel etc)

  • Select the controls in place:

  • Please describe:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Respirable dusts and or vapours (i.e. silica dust, asbestos, dust from abrasive blasting)

  • Select the controls in place:

  • Please describe:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Slips, Trips or Falls (i.e. Stair use, uneven/slippery ground)

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • With or near animals / exposed to bites or stings.

  • Select the controls in place:

  • Please describe:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Working at Heights

  • Select the controls in place:

  • Please describe:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Working in the vicinity of mobile plant / vehicles / traffic

  • Select the controls in place:

  • Please describe:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Any other site specific hazards that Maxima need to be aware of?

  • Please describe how the hazard may occur:

  • What controls are in place?

  • Please describe work activity:

  • 3.3 Summary of job tasks:

  • 3.4 Equipment, tools and plant to be used (Please list or provide a photo of all plant/equipment/machinery/tools to be used):

  • Please describe:

  • Please describe or provide a photo of the equipment above:

  • 3.4.2 Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Please describe or provide a photo of the equipment above:

  • 3.4.2 List any controls in place to avoid injury (i.e. Warning label on hot areas, written work instruction, etc):

  • Select the controls in place for motor vehicle use:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • 3.5 Substances, chemicals and materials to be used:

  • Attach photos above of:
    1. The substances / chemicals or materials present in their storage area; and
    2. Any spill containment kits
    3. Safety Data Sheet location

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • 3.6 Work Arrangements:

  • 3.7 Shift Start Time/s - Finish Time/s: Break Time/s or break duration:

  • 3.8 Who will directly oversee the safety of our workers day-to-day? (Please list the name and contact details of all Supervisors)

  • 3.9 Level of supervision to be provided:

  • 3.10 Training provided by your organisation before commencing work:

  • 3.10.1 Provide evidence of all applicable safe work procedures:

  • 3.11 If personal protective equipment is required, who will provide it?

  • Please describe who will provide what:

  • 3.12 What experience or qualifications are required to perform this work?

  • Please describe:

  • 3.13 Will your organisation arrange and or provide pre-employment screening, functional capacity or health monitoring? (i.e. pre–employment medical, hearing tests, drug & alcohol testing)

  • 3.13.1 Please describe what screening or monitoring will be provided by your organisation for Maxima worker/s:

  • Please describe:

  • 3.13.1 Do you require Maxima to arrange any pre-employment screening / medical prior to commencement? (Please list any special requirements (i.e. sleep test, full physical capabilities test, etc) in the "Note" section below.

4. Hazards in the workplace

  • Will the Job/Task require our worker to undertake or be exposed to any of the following? (select all that apply):

  • Biological materials (human waste, needle stick injury, blood, etc)

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Confined Spaces

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Conveyor belt use

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Electricity or electrical shock hazards

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Falling objects

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Fast pace

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Fatigue

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Hazardous manual tasks (i.e. computer work)

  • Select how the hazard could occur:

  • Please describe:

  • Select the controls in place:

  • Please describe:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Hot / cold work environments (i.e. cold air conditioning, near heat generating equipment)

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Loud noise levels which exceed the regulated standard in the general work environment (i.e. large crowd in a hall, using a phone headset, etc)

  • Select the controls in place and provide photographic evidence:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Multiple PCBU's / businesses operating in the same work area

  • Select the controls in place:

  • Other controls in place are:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • On or near water

  • Select the controls in place:

  • Other controls in place are:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Personal threat / duress (i.e. interacting with members of the public either face-to-face or on the phone)

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Pinch points (i.e. Safe doors, filing compactum, double hinged doors, etc)

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Poor lighting / glare

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Remote or Isolated (being alone – work, travel etc)

  • Select the controls in place:

  • Please describe:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Respirable dusts and or vapours (i.e. silica dust, asbestos, dust from abrasive blasting)

  • Select the controls in place:

  • Please describe:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Slips, Trips or Falls (i.e. Stair use, uneven/slippery ground)

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • With or near animals / exposed to bites or stings.

  • Select the controls in place:

  • Please describe:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Working at Heights

  • Select the controls in place:

  • Please describe:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Working in the vicinity of mobile plant / vehicles / traffic

  • Select the controls in place:

  • Please describe:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Any other site specific hazards that Maxima need to be aware of?

  • Please describe how the hazard may occur:

  • What controls are in place?

  • 3.3 Summary of job tasks:

  • 3.4 Equipment, tools and plant to be used (Please list or provide a photo of all plant/equipment/machinery/tools to be used):

  • Please describe:

  • Please describe or provide a photo of the equipment above:

  • 3.4.2 Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Please describe or provide a photo of the equipment above:

  • 3.4.2 List any controls in place to avoid injury (i.e. Warning label on hot areas, written work instruction, etc):

  • Select the controls in place for motor vehicle use:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • 3.5 Substances, chemicals and materials to be used:

  • Attach photos above of:
    1. The substances / chemicals or materials present in their storage area; and
    2. Any spill containment kits
    3. Safety Data Sheet location

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • 3.6 Work Arrangements:

  • 3.7 Shift Start Time/s - Finish Time/s: Break Time/s or break duration:

  • 3.8 Who will directly oversee the safety of our workers day-to-day? (Please list the name and contact details of all Supervisors)

  • 3.9 Level of supervision to be provided:

  • 3.10 Training provided by your organisation before commencing work:

  • 3.10.1 Provide evidence of all applicable safe work procedures:

  • 3.11 If personal protective equipment is required, who will provide it?

  • Please describe who will provide what:

  • 3.12 What experience or qualifications are required to perform this work?

  • Please describe:

  • 3.13 Will your organisation arrange and or provide pre-employment screening, functional capacity or health monitoring? (i.e. pre–employment medical, hearing tests, drug & alcohol testing)

  • 3.13.1 Please describe what screening or monitoring will be provided by your organisation for Maxima worker/s:

  • Please describe:

  • 3.13.1 Do you require Maxima to arrange any pre-employment screening / medical prior to commencement? (Please list any special requirements (i.e. sleep test, full physical capabilities test, etc) in the "Note" section below.

4. Hazards in the workplace

  • Will the Job/Task require our worker to undertake or be exposed to any of the following? (select all that apply):

  • Biological materials (human waste, needle stick injury, blood, etc)

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Confined Spaces

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Conveyor belt use

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Electricity or electrical shock hazards

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Falling objects

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Fast pace

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Fatigue

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Hazardous manual tasks (i.e. computer work)

  • Select how the hazard could occur:

  • Please describe:

  • Select the controls in place:

  • Please describe:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Hot / cold work environments (i.e. cold air conditioning, near heat generating equipment)

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Loud noise levels which exceed the regulated standard in the general work environment (i.e. large crowd in a hall, using a phone headset, etc)

  • Select the controls in place and provide photographic evidence:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Multiple PCBU's / businesses operating in the same work area

  • Select the controls in place:

  • Other controls in place are:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Personal threat / duress (i.e. interacting with members of the public either face-to-face or on the phone)

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Pinch points (i.e. Safe doors, filing compactum, double hinged doors, etc)

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Poor lighting / glare

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Remote or Isolated (being alone – work, travel etc)

  • Select the controls in place:

  • Please describe:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Slips, Trips or Falls (i.e. Stair use, uneven/slippery ground)

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • With or near animals / exposed to bites or stings.

  • Select the controls in place:

  • Please describe:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Working in the vicinity of mobile plant / vehicles / traffic

  • Select the controls in place:

  • Please describe:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Any other site specific hazards that Maxima need to be aware of?

  • Please describe how the hazard may occur:

  • What controls are in place?

  • 3.3 Summary of job tasks:

  • 3.4 Equipment, tools and plant to be used (Please list or provide a photo of all plant/equipment/machinery/tools to be used):

  • Please describe:

  • 3.4.2 Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Select the controls in place for motor vehicle use:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • 3.5 Substances, chemicals and materials to be used:

  • Attach photos above of:
    1. The substances / chemicals or materials present in their storage area; and
    2. Any spill containment kits
    3. Safety Data Sheet location

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • 3.6 Work Arrangements:

  • 3.7 Shift Start Time/s - Finish Time/s: Break Time/s or break duration:

  • 3.8 Who will directly oversee the safety of our workers day-to-day? (Please list the name and contact details of all Supervisors)

  • 3.9 Level of supervision to be provided:

  • 3.10 Training provided by your organisation before commencing work:

  • 3.10.1 Provide evidence of all applicable safe work procedures/ work instruction / SWMS / JSA:

  • 3.11 If personal protective equipment is required, who will provide it?

  • Please describe who will provide what:

  • 3.12 What experience or qualifications are required to perform this work?

  • Please describe:

  • 3.13 Will your organisation arrange and or provide pre-employment screening, functional capacity or health monitoring? (i.e. pre–employment medical, hearing tests, drug & alcohol testing)

  • 3.13.1 Please describe what screening or monitoring will be provided by your organisation for Maxima worker/s:

  • Please describe:

  • 3.13.1 Do you require Maxima to arrange any pre-employment screening / medical prior to commencement? (Please list any special requirements (i.e. sleep test, full physical capabilities test, etc) in the "Note" section below.

4. Hazards in the workplace

  • Will the Job/Task require our worker to undertake or be exposed to any of the following? (select all that apply):

  • Biological materials (human waste, needle stick injury, blood, etc)

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Confined Spaces

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Electricity or electrical shock hazards

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Falling objects

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Fast pace

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Fatigue

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Hazardous manual tasks (i.e. lifting, sustained postures)

  • Select how the hazard could occur:

  • Please describe:

  • Select the controls in place:

  • Please describe:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Hot / cold work environments (i.e. cold air conditioning, near heat generating equipment)

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Loud noise levels which exceed the regulated standard in the general work environment (i.e. large crowd in a hall, using a phone headset, etc)

  • Select the controls in place and provide photographic evidence:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Multiple PCBU's / businesses operating in the same work area

  • Select the controls in place:

  • Other controls in place are:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Personal threat / duress (i.e. interacting with members of the public either face-to-face or on the phone)

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Pinch points (i.e. Safe doors, filing compactum, double hinged doors, etc)

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Poor lighting / glare

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Remote or Isolated (being alone – work, travel etc)

  • Select the controls in place:

  • Please describe:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Respirable dusts and or vapours (i.e. flour / particles)

  • Select the controls in place:

  • Please describe:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Slips, Trips or Falls (i.e. Stair use, uneven/slippery ground)

  • Select the controls in place:

  • Describe what other controls are in place:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Working in the vicinity of mobile plant / vehicles / traffic

  • Select the controls in place:

  • Please describe:

  • A Maxima WHS Consultant may contact you for further information or to schedule a workplace inspection and risk assessment.

    Hazard Picture.JPG
  • Any other site specific hazards that Maxima need to be aware of?

  • Please describe how the hazard may occur:

  • What controls are in place?

4. Sign Off

4.1 Host Declaration

  • I have provided to the best of my knowledge accurate information regarding the work tasks, hazards and controls involved.

  • I understand that I must notify Maxima if the job or tasks changes which affects Maxima workers. Changes to job tasks may result in the need to reassess the safety provisions you have in place for the work performed by Maxima workers.

  • I understand that Maxima may need to complete workplace inspections / risk assessments on site where the work will be completed.

  • Host Representative Signature

  • Date & Time Completed:

  • Completed Host Employer Safety Self-Assessments are to be forwarded to WHSAction@maxima.com.au with supporting documentation / evidence for review.

Document Control

Version Control

  • Version 2: Global Response answers have been replaced with Responses (that have exactly the same options) so they can be accessible when the template is in the public library. The name of the template has been kept as (1) instead of (2) so that the document link may remain the same.

  • A secure Host file has been created and is located in: G:\Maxima WHS\Risk Assessments

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The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.