Information

  • Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

  • Job Number

  • Crew Leader

  • Start On Site

  • Finish on Site

  • SWMS Applicable

  • SWMS Applicable

  • SWMS Applicable

  • SWMS Applicable

  • SWMS Applicable

  • SWMS Applicable

  • SWMS Applicable

  • SWMS Applicable

  • SWMS Applicable

  • Vicinity Authority number From Issuing Officer

  • Nearest Medical Facility

  • Job Description

All Personnel PPE Checked

  • Helmet

  • Hearing Protection

  • Steel Cap Boots

  • Protective Eyewear

  • Hi Vis Clothing (Cotton)

  • Chainsaw Chaps or Trousers

  • Gloves

Other Checks

  • Traffic Management Template Used

  • Aerial Rescue climbing gear checked & positioned in an easy access area on-site/emergency plan discussed with crew

  • Names of two site members who hold a current first aid certificate

  • Names of two site members who are trained in Aeriel Rescue

  • Emergency Procedures & information are readily available

  • Tree Integrity checked and discussed

Environmental issues

  • What is the ESA information

  • Has DEC been advised about entry permits

Hazard Identification

What are the Potential Hazards

Vehicular Traffic

  • Hazard Present

  • What can go wrong (these are the Hazards) Where and what is the hazard on this specific worksite.

  • What Is The Risk? Use the Risk Matrix to evaluate the risk.

  • What can you do to Reduce Risks (These are the controls) list the control measures required to eliminate or minimize the risk/s.

  • What Is The Residual Risk? Use the Risk Matrix to re evaluate the risk.

  • Who is Responsible?

Pedestrian Traffic

  • Hazard Present

  • What can go wrong (these are the Hazards) Where and what is the hazard on this specific worksite.

  • What Is The Risk? Use the Risk Matrix to evaluate the risk.

  • What can you do to Reduce Risks (These are the controls) list the control measures required to eliminate or minimize the risk/s.

  • What Is The Risk? Use the Risk Matrix to evaluate the risk.

  • Who is Responsible?

Biological Hazards ( I.e pests,allergenic trees etc)

  • Hazard Present

  • What can go wrong (these are the Hazards) Where and what is the hazard on this specific worksite.

  • What Is The Risk? Use the Risk Matrix to evaluate the risk.

  • What can you do to Reduce Risks (These are the controls) list the control measures required to eliminate or minimize the risk/s.

  • What Is The Risk? Use the Risk Matrix to evaluate the risk.

  • Who is Responsible?

Environmental Conditions ( I.e adverse weather conditions, slippery surface etc)

  • Hazard Present

  • What can go wrong (these are the Hazards) Where and what is the hazard on this specific worksite.

  • What Is The Risk? Use the Risk Matrix to evaluate the risk.

  • What can you do to Reduce Risks (These are the controls) list the control measures required to eliminate or minimize the risk/s.

  • What Is The Risk? Use the Risk Matrix to evaluate the risk.

  • Who is Responsible?

Plant

  • Plant

  • Hazard Present

  • What can go wrong (these are the Hazards) Where and what is the hazard on this specific worksite.

  • What Is The Risk? Use the Risk Matrix to evaluate the risk.

  • What can you do to Reduce Risks (These are the controls) list the control measures required to eliminate or minimize the risk/s.

  • What Is The Risk? Use the Risk Matrix to evaluate the risk.

  • Who is Responsible?

Exposure to Noise

  • Hazard Present

  • What can go wrong (these are the Hazards) Where and what is the hazard on this specific worksite.

  • What Is The Risk? Use the Risk Matrix to evaluate the risk.

  • What can you do to Reduce Risks (These are the controls) list the control measures required to eliminate or minimize the risk/s.

  • What Is The Risk? Use the Risk Matrix to evaluate the risk.

  • Who is Responsible?

Manual Handling

  • Hazard Present

  • What can go wrong (these are the Hazards) Where and what is the hazard on this specific worksite.

  • What Is The Risk? Use the Risk Matrix to evaluate the risk.

  • What can you do to Reduce Risks (These are the controls) list the control measures required to eliminate or minimize the risk/s.

  • What Is The Risk? Use the Risk Matrix to evaluate the risk.

  • Who is Responsible?

Dangerous Goods ( fuel etc)

  • Hazard Present

  • What can go wrong (these are the Hazards) Where and what is the hazard on this specific worksite.

  • What Is The Risk? Use the Risk Matrix to evaluate the risk.

  • What can you do to Reduce Risks (These are the controls) list the control measures required to eliminate or minimize the risk/s.

  • What Is The Risk? Use the Risk Matrix to evaluate the risk.

  • Who is Responsible?

Overhead Services( I.e powerlines)

  • Hazard Present

  • What can go wrong (these are the Hazards) Where and what is the hazard on this specific worksite.

  • What Is The Risk? Use the Risk Matrix to evaluate the risk.

  • What can you do to Reduce Risks (These are the controls) list the control measures required to eliminate or minimize the risk/s.

  • What Is The Risk? Use the Risk Matrix to evaluate the risk.

  • Who is Responsible?

Underground Services

  • Hazard Present

  • What can go wrong (these are the Hazards) Where and what is the hazard on this specific worksite.

  • What Is The Risk? Use the Risk Matrix to evaluate the risk.

  • What can you do to Reduce Risks (These are the controls) list the control measures required to eliminate or minimize the risk/s.

  • What Is The Risk? Use the Risk Matrix to evaluate the risk.

  • Who is Responsible?

Property Damage Existing ( take photo)

  • Hazard Present

  • What can go wrong (these are the Hazards) Where and what is the hazard on this specific worksite.

  • What Is The Risk? Use the Risk Matrix to evaluate the risk.

  • What can you do to Reduce Risks (These are the controls) list the control measures required to eliminate or minimize the risk/s.

  • What Is The Risk? Use the Risk Matrix to evaluate the risk.

  • Who is Responsible?

Property Damage Possible (take photo)

  • Hazard Present

  • What can go wrong (these are the Hazards) Where and what is the hazard on this specific worksite.

  • What Is The Risk? Use the Risk Matrix to evaluate the risk.

  • What can you do to Reduce Risks (These are the controls) list the control measures required to eliminate or minimize the risk/s.

  • What can you do to Reduce Risks (These are the controls) list the control measures required to eliminate or minimize the risk/s.

  • What Is The Risk? Use the Risk Matrix to evaluate the risk.

  • Who is Responsible?

Other Potential Hazards

Hazard 1

  • Hazard Present

  • What can go wrong (these are the Hazards) Where and what is the hazard on this specific worksite.

  • What Is The Risk? Use the Risk Matrix to evaluate the risk.

  • What can you do to Reduce Risks (These are the controls) list the control measures required to eliminate or minimize the risk/s.

  • What Is The Risk? Use the Risk Matrix to evaluate the risk.

  • Who is Responsible?

Hazard 2

  • Hazard Present

  • What can go wrong (these are the Hazards) Where and what is the hazard on this specific worksite.

  • What Is The Risk? Use the Risk Matrix to evaluate the risk.

  • What can you do to Reduce Risks (These are the controls) list the control measures required to eliminate or minimize the risk/s.

  • What Is The Risk? Use the Risk Matrix to evaluate the risk.

  • Who is Responsible?

Hazard 3

  • Hazard Present

  • What can go wrong (these are the Hazards) Where and what is the hazard on this specific worksite.

  • What Is The Risk? Use the Risk Matrix to evaluate the risk.

  • What can you do to Reduce Risks (These are the controls) list the control measures required to eliminate or minimize the risk/s.

  • What Is The Risk? Use the Risk Matrix to evaluate the risk.

  • Who is Responsible?

Additional Information When When Working Near Powerlines

  • Refer to Section 10 of Western Power Work Practice Manual.

  • Identify what Voltage you are working with

  • What plant Clearance is required for the identified voltage

  • What Is the Ground Approach Distance (GAD)

  • Identify what Service Wires you are working around

  • Witnessed and Sighted by ALL CREW MEMBERS ON - SITE BEFORE COMMENCEMENT OF WORKS - I acknowledge that I have discussed and understand the above mentioned potential hazards and control measure pertaining to this particular work site, and I am satisfied that the job can proceed safely.

  • Crew Member

  • Crew Member

  • Crew Member

  • Crew Member

  • Crew Member

  • Crew Member

  • Crew Member

  • Crew Member

  • Crew Member

  • Crew Member

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.