HRA GF101-11(4)

• Host Trading Name (Select site):

  Select

• Host Business Name

• Risk Assessment Location
  Address

• Suburb / Area and State assessment is applicable to:

• Vocations:

  Select

• Job Title/s of roles to be placed (add number for each one)

• Prepared by Maxima Risk Assessor:

• Conducted on

  Date

• Assessment due date (must be completed within 10 business days of date conducted)

  Date

• Due date for review of host risk assessment:

  Date

• Review dates - Low Residual Risk: < 3 years from date conducted. Medium Residual Risk: < 2 years from date conducted. High Residual Risk: Do not supply employees for the role/s.

• Have you conducted or reviewed the Host Risk Assessment for this client within the past 2 years?

  Yes

  No

• Have there been any changes to the WHS management system, legislative requirements or tasks completed by Maxima host-based employees since the last Host Risk Assessment was completed?

  Yes

  No

  N/A

• Is the inherent level of risk with the roles being assessed low? Examples of low risk roles are administration officer, post office worker, bank customer service/teller. In these roles, the worker is not exposed to moving heavy vehicles, such as forklifts, dangerous chemicals, hazardous manual tasks, excessive noise and hand and body vibration, risk of falling from height, etc.

  Yes

  No

WHS Management System

• A return to work policy and procedure that support Maxima workers with suitable duties for work or non-work related duties?

  Select Yes, Work Related Injury Only Yes, Work and Non-Work Related Injury No, Host will not provide suitable duties May provide suitable duties upon request

  • Yes, Work Related Injury Only
  • Yes, Work and Non-Work Related Injury
  • No, Host will not provide suitable duties
  • May provide suitable duties upon request

• A documented WHS policy?

  Yes

  No

  N/A

• A documented WHS management system including procedures and tools?

  Yes

  No

  N/A

• Accountability for WHS responsibilities documented?

  Yes

  No

  N/A

• Documented hazard identification, risk assessment and control for plant, tasks, confined spaces and chemicals?

  Yes

  No

  N/A

• Access to hazard and incident reporting process that includes investigation?

  Yes

  No

  N/A

• What health monitoring is required prior to and/or during placement of Maxima employees?

  Select

• If the host employer does not require pre-employment or functional capacity assessment, as the employer you may still deem it a reasonably practicable control. This should be documented on the relevant Task Risk Assessment.

• National heavy vehicle obligations documented for heavy vehicles associated with their operations?

  Yes

  No

  N/A

• Does the documentation cover requirements for?

  Select Mass and dimensions Fatigue management Speed compliance Loading and load restraint Maintenance and vehicle standards

  • Mass and dimensions
  • Fatigue management
  • Speed compliance
  • Loading and load restraint
  • Maintenance and vehicle standards

Induction, Information, Training & Equipment

• Does the host employer have a formal induction process?

  Yes

  No

  N/A

• Does the host employer provide employees with information, training and supervision to ensure they perform the work safely?

  Yes

  No

  N/A

• Does the host employer keep occupational health and safety and other training records?

  Yes

  No

  N/A

• Is there a competency assessment and licensing process in place for complex or higher risk tasks or plant / equipment operation?

  Yes

  No

  N/A

• Is there a process to involve workers in workplace health and safety issues? (For example, consultation/toolbox meetings with two-way flow of information/occupational health and safety committee)

  Yes

  No

  N/A

• What are the highest risk emergency events the host prepares workers to respond to?

• Is the worker provided with the information on emergency procedures and access to adequate first aid facilities?

  Yes

  No

  N/A

• Can the worker suffer fatigue because they have to work irregular or extended hours of work or at a pace which is too fast (difficult to maintain) or too slow? E.g., extended overtime, intense or low cognitive demands

  Yes

  No

  N/A

• Has the host addressed the risk of psychological injury to the worker as a result of sexual harassment, intimidation, violence or verbal abuse?

  Yes

  No

  N/A

• Is there a possibility of the worker not being able to communicate with their colleague(s) in the event of an incident/emergency or injury? E.g., remote or isolated work

  Yes

  No

  N/A

• The following PPE&C is mandatory for the role/s:

  Select

• The Host will provide the following required PPE / Workwear:

• WHS & Risk Team must complete or participate in host risk assessments where inherent risk is medium or above.

WHS Management System

• A return to work policy and procedure that support Maxima workers with suitable duties for work or non-work related duties?

  Select Yes, Work Related Injury Only Yes, Work and Non-Work Related Injury No, Host will not provide suitable duties May provide suitable duties upon request

  • Yes, Work Related Injury Only
  • Yes, Work and Non-Work Related Injury
  • No, Host will not provide suitable duties
  • May provide suitable duties upon request

• A documented WHS policy?

  Yes

  No

  N/A

• Accountability for WHS responsibilities documented?

  Yes

  No

  N/A

• A documented WHS management system including procedures and tools?

  Yes

  No

  N/A

• Documented hazard identification, risk assessment and control for plant, tasks, confined spaces and chemicals?

  Yes

  No

  N/A

• Access to hazard and incident reporting process that includes investigation?

  Yes

  No

  N/A

• Suitable duties available for supporting work related and non-work related injury management?

  Select Yes, Work Related Injury Only Yes, Work and Non-Work Related Injury No, Host will not provide suitable duties May provide suitable duties upon request

  • Yes, Work Related Injury Only
  • Yes, Work and Non-Work Related Injury
  • No, Host will not provide suitable duties
  • May provide suitable duties upon request

• National heavy vehicle obligations documented for heavy vehicles associated with their operations?

  Yes

  No

  N/A

• Does the documentation cover requirements for?

  Select Mass and dimensions Fatigue management Speed compliance Loading and load restraint Maintenance and vehicle standards

  • Mass and dimensions
  • Fatigue management
  • Speed compliance
  • Loading and load restraint
  • Maintenance and vehicle standards

Induction, Information, Instruction and Equipment

• Does the host employer have a formal induction process?

  Yes

  No

  N/A

• Does the host employer provide employees with information, training and supervision to ensure they perform the work safely?

  Yes

  No

  N/A

• Does the host employer keep occupational health and safety and other training records?

  Yes

  No

  N/A

• Is there a competency assessment and licensing process in place for complex or higher risk tasks or plant / equipment operation?

  Yes

  No

  N/A

• Is there a process to involve workers in workplace health and safety issues? (For example, consultation/toolbox meetings with two-way flow of information/occupational health and safety committee)

  Yes

  No

  N/A

• What are the highest risk emergency events the host prepares workers to respond to?

• Is the worker provided with the information on emergency procedures and access to adequate first aid facilities?

  Yes

  No

  N/A

• Can the worker suffer fatigue because they have to work irregular or extended hours of work or at a pace which is too fast (difficult to maintain) or too slow? E.g., extended overtime, intense or low cognitive demands

  Yes

  No

  N/A

• Has the host addressed the risk of psychological injury to the worker as a result of sexual harassment, intimidation, violence or verbal abuse?

  Yes

  No

  N/A

• Is there a possibility of the worker not being able to communicate with their colleague(s) in the event of an incident/emergency or injury? E.g., remote or isolated work

  Yes

  No

  N/A

• The following PPE&C is mandatory for the role/s:

  Select

• The Host will provide the following required PPE / Workwear:

• Is the inherent level of risk with the roles being assessed low? Examples of low risk roles are administration officer, post office worker, bank customer service/teller. In these roles, the worker is not exposed to moving heavy vehicles, such as forklifts, dangerous chemicals, hazardous manual tasks, excessive noise and hand and body vibration, risk of falling from height, etc.

  Yes

  No

WHS Management System

• A return to work policy and procedure that support Maxima workers with suitable duties for work or non-work related duties?

  Select Yes, Work Related Injury Only Yes, Work and Non-Work Related Injury No, Host will not provide suitable duties May provide suitable duties upon request

  • Yes, Work Related Injury Only
  • Yes, Work and Non-Work Related Injury
  • No, Host will not provide suitable duties
  • May provide suitable duties upon request

• A documented WHS policy?

  Yes

  No

  N/A

• Accountability for WHS responsibilities documented?

  Yes

  No

  N/A

• A documented WHS management system including procedures and tools?

  Yes

  No

  N/A

• Documented hazard identification, risk assessment and control for plant, tasks, confined spaces and chemicals?

  Yes

  No

  N/A

• Access to hazard and incident reporting process that includes investigation?

  Yes

  No

  N/A

• Suitable duties available for supporting work related and non-work related injury management?

  Select Yes, Work Related Injury Only Yes, Work and Non-Work Related Injury No, Host will not provide suitable duties May provide suitable duties upon request

  • Yes, Work Related Injury Only
  • Yes, Work and Non-Work Related Injury
  • No, Host will not provide suitable duties
  • May provide suitable duties upon request

• National heavy vehicle obligations documented for heavy vehicles associated with their operations?

  Yes

  No

  N/A

• Does the documentation cover requirements for?

  Select Mass and dimensions Fatigue management Speed compliance Loading and load restraint Maintenance and vehicle standards

  • Mass and dimensions
  • Fatigue management
  • Speed compliance
  • Loading and load restraint
  • Maintenance and vehicle standards

Induction, Information, Instruction and Equipment

• Does the host employer have a formal induction process?

  Yes

  No

  N/A

• Does the host employer provide employees with information, training and supervision to ensure they perform the work safely?

  Yes

  No

  N/A

• Does the host employer keep occupational health and safety and other training records?

  Yes

  No

  N/A

• Is there a competency assessment and licensing process in place for complex or higher risk tasks or plant / equipment operation?

  Yes

  No

  N/A

• Is there a process to involve workers in workplace health and safety issues? (For example, consultation/toolbox meetings with two-way flow of information/occupational health and safety committee)

  Yes

  No

  N/A

• What are the highest risk emergency events the host prepares workers to respond to?

• Is the worker provided with the information on emergency procedures and access to adequate first aid facilities?

  Yes

  No

  N/A

• Can the worker suffer fatigue because they have to work irregular or extended hours of work or at a pace which is too fast (difficult to maintain) or too slow? E.g., extended overtime, intense or low cognitive demands

  Yes

  No

  N/A

• Has the host addressed the risk of psychological injury to the worker as a result of sexual harassment, intimidation, violence or verbal abuse?

  Yes

  No

  N/A

• Is there a possibility of the worker not being able to communicate with their colleague(s) in the event of an incident/emergency or injury? E.g., remote or isolated work

  Yes

  No

  N/A

• The following PPE&C is mandatory for the role/s:

  Select

• The Host will provide the following required PPE / Workwear:

• WHS & Risk Team must complete or participate in host risk assessments where inherent risk is medium or above.

WHS Management System

• A return to work policy and procedure that support Maxima workers with suitable duties for work or non-work related duties?

  Select Yes, Work Related Injury Only Yes, Work and Non-Work Related Injury No, Host will not provide suitable duties May provide suitable duties upon request

  • Yes, Work Related Injury Only
  • Yes, Work and Non-Work Related Injury
  • No, Host will not provide suitable duties
  • May provide suitable duties upon request

• A documented WHS policy?

  Yes

  No

  N/A

• Accountability for WHS responsibilities documented?

  Yes

  No

  N/A

• A documented WHS management system including procedures and tools?

  Yes

  No

  N/A

• Documented hazard identification, risk assessment and control for plant, tasks, confined spaces and chemicals?

  Yes

  No

  N/A

• Access to hazard and incident reporting process that includes investigation?

  Yes

  No

  N/A

• Suitable duties available for supporting work related and non-work related injury management?

  Select Yes, Work Related Injury Only Yes, Work and Non-Work Related Injury No, Host will not provide suitable duties May provide suitable duties upon request

  • Yes, Work Related Injury Only
  • Yes, Work and Non-Work Related Injury
  • No, Host will not provide suitable duties
  • May provide suitable duties upon request

• National heavy vehicle obligations documented for heavy vehicles associated with their operations?

  Yes

  No

  N/A

• Does the documentation cover requirements for?

  Select Mass and dimensions Fatigue management Speed compliance Loading and load restraint Maintenance and vehicle standards

  • Mass and dimensions
  • Fatigue management
  • Speed compliance
  • Loading and load restraint
  • Maintenance and vehicle standards

Induction, Information, Instruction and Equipment

• Does the host employer have a formal induction process?

  Yes

  No

  N/A

• Does the host employer provide employees with information, training and supervision to ensure they perform the work safely?

  Yes

  No

  N/A

• Does the host employer keep occupational health and safety and other training records?

  Yes

  No

  N/A

• Is there a competency assessment and licensing process in place for complex or higher risk tasks or plant / equipment operation?

  Yes

  No

  N/A

• Is there a process to involve workers in workplace health and safety issues? (For example, consultation/toolbox meetings with two-way flow of information/occupational health and safety committee)

  Yes

  No

  N/A

• What are the highest risk emergency events the host prepares workers to respond to?

• Is the worker provided with the information on emergency procedures and access to adequate first aid facilities?

  Yes

  No

  N/A

• Can the worker suffer fatigue because they have to work irregular or extended hours of work or at a pace which is too fast (difficult to maintain) or too slow? E.g., extended overtime, intense or low cognitive demands

  Yes

  No

  N/A

• Has the host addressed the risk of psychological injury to the worker as a result of sexual harassment, intimidation, violence or verbal abuse?

  Yes

  No

  N/A

• Is there a possibility of the worker not being able to communicate with their colleague(s) in the event of an incident/emergency or injury? E.g., remote or isolated work

  Yes

  No

  N/A

• The following PPE&C is mandatory for the role/s:

  Select

• The Host will provide the following required PPE / Workwear:

WHS Management System

• A return to work policy and procedure that support Maxima workers with suitable duties for work or non-work related duties?

  Select Yes, Work Related Injury Only Yes, Work and Non-Work Related Injury No, Host will not provide suitable duties May provide suitable duties upon request

  • Yes, Work Related Injury Only
  • Yes, Work and Non-Work Related Injury
  • No, Host will not provide suitable duties
  • May provide suitable duties upon request

• A documented WHS policy?

  Yes

  No

  N/A

• Accountability for WHS responsibilities documented?

  Yes

  No

  N/A

• A documented WHS management system including procedures and tools?

  Yes

  No

  N/A

• Documented hazard identification, risk assessment and control for plant, tasks, confined spaces and chemicals?

  Yes

  No

  N/A

• Access to hazard and incident reporting process that includes investigation?

  Yes

  No

  N/A

• Suitable duties available for supporting work related and non-work related injury management?

  Select Yes, Work Related Injury Only Yes, Work and Non-Work Related Injury No, Host will not provide suitable duties May provide suitable duties upon request

  • Yes, Work Related Injury Only
  • Yes, Work and Non-Work Related Injury
  • No, Host will not provide suitable duties
  • May provide suitable duties upon request

• National heavy vehicle obligations documented for heavy vehicles associated with their operations?

  Yes

  No

  N/A

• Does the documentation cover requirements for?

  Select Mass and dimensions Fatigue management Speed compliance Loading and load restraint Maintenance and vehicle standards

  • Mass and dimensions
  • Fatigue management
  • Speed compliance
  • Loading and load restraint
  • Maintenance and vehicle standards

Induction, Information, Instruction and Equipment

• Does the host employer have a formal induction process?

  Yes

  No

  N/A

• Does the host employer provide employees with information, training and supervision to ensure they perform the work safely?

  Yes

  No

  N/A

• Does the host employer keep occupational health and safety and other training records?

  Yes

  No

  N/A

• Is there a competency assessment and licensing process in place for complex or higher risk tasks or plant / equipment operation?

  Yes

  No

  N/A

• Is there a process to involve workers in workplace health and safety issues? (For example, consultation/toolbox meetings with two-way flow of information/occupational health and safety committee)

  Yes

  No

  N/A

• What are the highest risk emergency events the host prepares workers to respond to?

• Is the worker provided with the information on emergency procedures and access to adequate first aid facilities?

  Yes

  No

  N/A

• Can the worker suffer fatigue because they have to work irregular or extended hours of work or at a pace which is too fast (difficult to maintain) or too slow? E.g., extended overtime, intense or low cognitive demands

  Yes

  No

  N/A

• Has the host addressed the risk of psychological injury to the worker as a result of sexual harassment, intimidation, violence or verbal abuse?

  Yes

  No

  N/A

• Is there a possibility of the worker not being able to communicate with their colleague(s) in the event of an incident/emergency or injury? E.g., remote or isolated work

  Yes

  No

  N/A

• The following PPE&C is mandatory for the role/s:

  Select

• The Host will provide the following required PPE / Workwear:

• Is the inherent level of risk with the roles being assessed low? Examples of low risk roles are administration officer, post office worker, bank customer service/teller. In these roles, the worker is not exposed to moving heavy vehicles, such as forklifts, dangerous chemicals, hazardous manual tasks, excessive noise and hand and body vibration, risk of falling from height, etc.

  Yes

  No

• WHS & Risk Team must complete or participate in host risk assessments where inherent risk is medium or above.

WHS Management System

• A return to work policy and procedure that support Maxima workers with suitable duties for work or non-work related duties?

  Select Yes, Work Related Injury Only Yes, Work and Non-Work Related Injury No, Host will not provide suitable duties May provide suitable duties upon request

  • Yes, Work Related Injury Only
  • Yes, Work and Non-Work Related Injury
  • No, Host will not provide suitable duties
  • May provide suitable duties upon request

• A documented WHS policy?

  Yes

  No

  N/A

• Accountability for WHS responsibilities documented?

  Yes

  No

  N/A

• A documented WHS management system including procedures and tools?

  Yes

  No

  N/A

• Documented hazard identification, risk assessment and control for plant, tasks, confined spaces and chemicals?

  Yes

  No

  N/A

• Access to hazard and incident reporting process that includes investigation?

  Yes

  No

  N/A

• Suitable duties available for supporting work related and non-work related injury management?

  Select Yes, Work Related Injury Only Yes, Work and Non-Work Related Injury No, Host will not provide suitable duties May provide suitable duties upon request

  • Yes, Work Related Injury Only
  • Yes, Work and Non-Work Related Injury
  • No, Host will not provide suitable duties
  • May provide suitable duties upon request

• National heavy vehicle obligations documented for heavy vehicles associated with their operations?

  Yes

  No

  N/A

• Does the documentation cover requirements for?

  Select Mass and dimensions Fatigue management Speed compliance Loading and load restraint Maintenance and vehicle standards

  • Mass and dimensions
  • Fatigue management
  • Speed compliance
  • Loading and load restraint
  • Maintenance and vehicle standards

Induction, Information, Instruction and Equipment

• Does the host employer have a formal induction process?

  Yes

  No

  N/A

• Does the host employer provide employees with information, training and supervision to ensure they perform the work safely?

  Yes

  No

  N/A

• Does the host employer keep occupational health and safety and other training records?

  Yes

  No

  N/A

• Is there a competency assessment and licensing process in place for complex or higher risk tasks or plant / equipment operation?

  Yes

  No

  N/A

• Is there a process to involve workers in workplace health and safety issues? (For example, consultation/toolbox meetings with two-way flow of information/occupational health and safety committee)

  Yes

  No

  N/A

• What are the highest risk emergency events the host prepares workers to respond to?

• Is the worker provided with the information on emergency procedures and access to adequate first aid facilities?

  Yes

  No

  N/A

• Can the worker suffer fatigue because they have to work irregular or extended hours of work or at a pace which is too fast (difficult to maintain) or too slow? E.g., extended overtime, intense or low cognitive demands

  Yes

  No

  N/A

• Has the host addressed the risk of psychological injury to the worker as a result of sexual harassment, intimidation, violence or verbal abuse?

  Yes

  No

  N/A

• Is there a possibility of the worker not being able to communicate with their colleague(s) in the event of an incident/emergency or injury? E.g., remote or isolated work

  Yes

  No

  N/A

• The following PPE&C is mandatory for the role/s:

  Select

• The Host will provide the following required PPE / Workwear:

Supervision

• Who will oversee the safety of Maxima employees day-to-day?

• A supervisor or representative from the host will provide the Maxima placement consultant with induction records for all new starting Maxima employees?

  Yes

  No

• WHS expertise (name/s, position/s, contact/s):

• Rehabilitation and Return to Work Coordinator (name/s, position/s, contact/s):

• Does the supervisor have adequate technical, supervisory and communications knowledge and skills? (For Group Training and IEP, obtain copies of trade certificates, builders license etc)

  Yes

  No

  N/A

• What level of supervision is required? E.g., trainees and apprentices may need continuous level of supervision

  Select

Task Risk Assessment

• Will the host provide copies of their task risk assessment (TRA) or job safety analysis (JSA) or similar?

  Yes

  No

  N/A

• Have you completed and verified through a documented task risk assessment that all roles have a medium or low residual risk rating? (Attach completed task risk assessments below).

  Yes

  No

  N/A

• Please complete and upload task risk assessment/s for job roles with medium or above inherent risk ratings in consultation with the host representative. Template 'Maxima Task Risk Assessment' documents are available via the link -

• https://maximatraininggroup.sharepoint.com/sites/365WHSTeam/Shared%20Documents/Forms/AllItems.aspx?id=%2Fsites%2F365WHSTeam%2FShared%20Documents%2FGeneral%2FHost%20Risk%20Assessments%2FMaxima%20Task%20Risk%20Assessments%20%28for%20Host%20Based%20Employees%29&viewid=c8c770c8%2Dc8a3%2D4b7d%2D9289%2D3093fb05c6f8

• Will the host require Maxima workers to conduct any high-risk construction work? Refer to Model Code of Practice - Construction Work - 21102022 .pdf (safeworkaustralia.gov.au)

  Yes

  No

• What has been captured within the SWMS (verify legislative requirements)?

  Select

• Please request the host provides copies of Safe Work Method Statements relevant to roles Maxima may supply workers and raise an action to obtain signed copies of all Safe Work Method Statements (SWMS) relevant to Maxima Workers.

Additional Comments & Photographic Evidence

• Add additional comments here:

• Competent person (Recruitment or WHS consultant) is to observe the workplace, equipment and amenities in confirming the host has controlled work environment risks and provided facilities to or above the standards set within Model Code of Practice: Management the work environment and facilities). Photos should be taken and added to the host risk assessment to evidence risk controls and amenities.

Work Environment

• Has a Maxima WHS Consultant inspected the work environment in the last 2 years?

  Yes

  No

• Month and year of last inspection:

• Have there been any changes in the environment or facilities provided since the last Host Risk Assessment was completed?

  Yes

  No

  N/A

• Please select what risks exist in the work environment.

• Asbestos

  Yes

  No

• Controlled to acceptable risk by the following:

  Select

• What is the residual risk level?

  Low

  Medium

  High

• Dust, Crystalline silica, flying particles

  Yes

  No

• Controlled to acceptable risk by the following:

  Select

• What is the residual risk level?

  Low

  Medium

  High

• Fumes, particles from hazardous substances

  Yes

  No

• Controlled to acceptable risk by the following:

  Select

• What is the residual risk level?

  Low

  Medium

  High

• Occupational noise

  Yes

  No

• Controlled to acceptable risk by the following:

  Select

• What is the residual risk level?

  Low

  Medium

  High

• Falling objects

  Yes

  No

• Controlled to acceptable risk by the following:

  Select

• What is the residual risk level?

  Low

  Medium

  High

• Vehicles and/or pedestrian interactions

  Yes

  No

• Controlled to acceptable risk by the following:

  Select

• What is the residual risk level?

  Low

  Medium

  High

• Heat, cold (exposure to extreme)

  Yes

  No

• Controlled to acceptable risk by the following:

  Select

• What is the residual risk level?

  Low

  Medium

  High

• Other hazards identified?

  Yes

  No

• List of hazards:

• Controlled to acceptable risk by the following:

Amenities - are workers provided with the following in good condition:

• Ready access to weatherproof toilets which are clean and provide adequate privacy and security?

  Yes

  No

• Ready access to weatherproof, clean hand and body washing and facilities?

  Yes

  No

• Ready supply of cool drinking water available?

  Yes

  No

• Are there facilities or reasonable arrangements to allow for the consumption of a meal?

  Yes

  No

• Does the worker have access to facilities or reasonable arrangements to secure personal belongings?

  Yes

  No

• Asbestos

  Yes

  No

  N/A

• Controlled to acceptable risk by the following:

  Select

• Dust, Crystalline silica, flying particles

  Yes

  No

  N/A

• Controlled to acceptable risk by the following:

  Select

• Fumes, particles from hazardous substances

  Yes

  No

  N/A

• Controlled to acceptable risk by the following:

  Select

• Occupational noise

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Controlled to acceptable risk by the following:

  Select

• Falling objects

  Yes

  No

  N/A

• Controlled to acceptable risk by the following:

  Select

• Vehicles and/or pedestrian interactions

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Controlled to acceptable risk by the following:

  Select

• Heat, cold (exposure to extreme)

  Yes

  No

  N/A

• Controlled to acceptable risk by the following:

  Select

• Other hazards identified?

  Yes

  No

• List of hazards:

• Controlled to acceptable risk by the following:

Amenities - are workers provided with the following in good condition:

• Ready access to weatherproof toilets which are clean and provide adequate privacy and security?

  Yes

  No

• Ready access to weatherproof, clean hand and body washing and facilities?

  Yes

  No

• Ready supply of cool drinking water available?

  Yes

  No

• Are there facilities or reasonable arrangements to allow for the consumption of a meal?

  Yes

  No

• Does the worker have access to facilities or reasonable arrangements to secure personal belongings?

  Yes

  No

• Attach photographs of the work environment hazards and risk controls and facilities from visiting the site/s or the host contact providing (if remote risk assessment).

  Media

• Please indicate what risks exist in the work environment.

• Asbestos

  Yes

  No

• Controlled to acceptable risk by the following:

  Select

• What is the residual risk level?

  Low

  Medium

  High

• Dust, Crystalline silica, flying particles

  Yes

  No

• Controlled to acceptable risk by the following:

  Select

• What is the residual risk level?

  Low

  Medium

  High

• Fumes, particles from hazardous substances

  Yes

  No

• Controlled to acceptable risk by the following:

  Select

• What is the residual risk level?

  Low

  Medium

  High

• Occupational noise

  Yes

  No

• Controlled to acceptable risk by the following:

  Select

• What is the residual risk level?

  Low

  Medium

  High

• Falling objects

  Yes

  No

• Controlled to acceptable risk by the following:

  Select

• What is the residual risk level?

  Low

  Medium

  High

• Vehicles and/or pedestrian interactions

  Yes

  No

• Controlled to acceptable risk by the following:

  Select

• What is the residual risk level?

  Low

  Medium

  High

• Heat, cold (exposure to extreme)

  Yes

  No

• Controlled to acceptable risk by the following:

  Select

• What is the residual risk level?

  Low

  Medium

  High

• Other hazards identified?

  Yes

  No

• List of hazards:

• Controlled to acceptable risk by the following:

Additional Comments & Photographic Evidence

• Add additional comments here:

• Attach photographs of the work environment hazards and risk controls and facilities from visiting the site/s or the host contact providing.

  Media

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

• As per workplace health and safety legislation, I understand that I must consult with Maxima and their workers of all changes to job tasks / role requirements (including the use of any additional tools, plant or equipment and documented procedures), amenities provided, first aid and emergency response equipment that could impact the health and safety of Maxima workers which have not been included in this risk assessment. I also understand that these changes may need to be assessed by Maxima and could trigger a risk assessment or workplace visit.

• I agree to provide Maxima with a copy of the induction completed for all new starting Maxima employees when submitting each new starters first time sheet.

• I understand that Maxima will need to maintain regular contact and monitoring of Maxima workers as per the relevant Government Regulator and Legislation or Labour Hire Licensing requirements. This may also include the need to conduct additional workplace inspections / risk assessments on site or remotely.

• Host Representative Name & Signature:

  Sign

• Date & Time Completed:

  Date

Privacy & Information Collection Notice

• Maxima are committed to preserving the confidentiality of information supplied to it by customers, potential customers, enterprises or individuals involved in joint or collaborative projects, trainees, on-hire employees, staff, jobseekers, participants and other agencies both government and non-government.
  
  Maxima will treat all such documents and information which comes to their knowledge, or to which they are exposed, as being strictly confidential. All documents, pictures, evidence gathered to complete this form are kept in a secure location and are only accessible by select employees of Maxima. 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.

Risk Assessor Sign Off

• The risk assessor must verify that based on assessment of the host's WHS management system, work environment and task risk assessment/s (if applicable) that host-based employees will be protected against high or extreme residual risk conditions and tasks. If recommended actions cannot be agreed to between Maxima and the host employer representatives, please escalate to the WHS & Risk Manager and relevant State General Manager.

• Based on the items assessed, made available and discussed (select all applicable statements):

  Select

• Maxima Consultant Name and Signature:

  Sign

• Date and Time Conducted:

  Date

Additional Comments

• Additional comments or the placement's name/s if known: