
Job Number

Crew Leader

Start On Site

Finish on Site

SWMS Applicable
 EWP Tree Cutting
 Tree Climbing
 Tree Cutting from the Ground
 Tree Felling
 Regrowth Herbicide
 Chipper
 Stump Grinding
 Fire Fighting
 slashing/Flail Mowing
 Brushcutting

SWMS Applicable
 EWP Tree Cutting
 Tree Climbing
 Tree Cutting from the Ground
 Tree Felling
 Regrowth Herbicide
 Chipper
 Stump Grinding
 Fire Fighting
 slashing/Flail Mowing
 Brushcutting

SWMS Applicable
 EWP Tree Cutting
 Tree Climbing
 Tree Cutting from the Ground
 Tree Felling
 Regrowth Herbicide
 Chipper
 Stump Grinding
 Fire Fighting
 slashing/Flail Mowing
 Brushcutting

SWMS Applicable
 EWP Tree Cutting
 Tree Climbing
 Tree Cutting from the Ground
 Tree Felling
 Regrowth Herbicide
 Chipper
 Stump Grinding
 Fire Fighting
 slashing/Flail Mowing
 Brushcutting

SWMS Applicable
 EWP Tree Cutting
 Tree Climbing
 Tree Cutting from the Ground
 Tree Felling
 Regrowth Herbicide
 Chipper
 Stump Grinding
 Fire Fighting
 slashing/Flail Mowing
 Brushcutting

SWMS Applicable
 EWP Tree Cutting
 Tree Climbing
 Tree Cutting from the Ground
 Tree Felling
 Regrowth Herbicide
 Chipper
 Stump Grinding
 Fire Fighting
 slashing/Flail Mowing
 Brushcutting

SWMS Applicable
 EWP Tree Cutting
 Tree Climbing
 Tree Cutting from the Ground
 Tree Felling
 Regrowth Herbicide
 Chipper
 Stump Grinding
 Fire Fighting
 slashing/Flail Mowing
 Brushcutting

SWMS Applicable
 EWP Tree Cutting
 Tree Climbing
 Tree Cutting from the Ground
 Tree Felling
 Regrowth Herbicide
 Chipper
 Stump Grinding
 Fire Fighting
 slashing/Flail Mowing
 Brushcutting

SWMS Applicable
 EWP Tree Cutting
 Tree Climbing
 Tree Cutting from the Ground
 Tree Felling
 Regrowth Herbicide
 Chipper
 Stump Grinding
 Fire Fighting
 slashing/Flail Mowing
 Brushcutting

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 onsite/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.
 Negligible
 Very Low
 Low
 Medium
 High
 Urgent
 Critical

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.
 Negligible
 Very Low
 Low
 Medium
 High
 Urgent
 Critical

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.
 Negligible
 Very Low
 Low
 Medium
 High
 Urgent
 Critical

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.
 Negligible
 Very Low
 Low
 Medium
 High
 Urgent
 Critical

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.
 Negligible
 Very Low
 Low
 Medium
 High
 Urgent
 Critical

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.
 Negligible
 Very Low
 Low
 Medium
 High
 Urgent
 Critical

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.
 Negligible
 Very Low
 Low
 Medium
 High
 Urgent
 Critical

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.
 Negligible
 Very Low
 Low
 Medium
 High
 Urgent
 Critical

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.
 Negligible
 Very Low
 Low
 Medium
 High
 Urgent
 Critical

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.
 Negligible
 Very Low
 Low
 Medium
 High
 Urgent
 Critical

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.
 Negligible
 Very Low
 Low
 Medium
 High
 Urgent
 Critical

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.
 Negligible
 Very Low
 Low
 Medium
 High
 Urgent
 Critical

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.
 Negligible
 Very Low
 Low
 Medium
 High
 Urgent
 Critical

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.
 Negligible
 Very Low
 Low
 Medium
 High
 Urgent
 Critical

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.
 Negligible
 Very Low
 Low
 Medium
 High
 Urgent
 Critical

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.
 Negligible
 Very Low
 Low
 Medium
 High
 Urgent
 Critical

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.
 Negligible
 Very Low
 Low
 Medium
 High
 Urgent
 Critical

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.
 Negligible
 Very Low
 Low
 Medium
 High
 Urgent
 Critical

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.
 Negligible
 Very Low
 Low
 Medium
 High
 Urgent
 Critical

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.
 Negligible
 Very Low
 Low
 Medium
 High
 Urgent
 Critical

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.
 Negligible
 Very Low
 Low
 Medium
 High
 Urgent
 Critical

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.
 Negligible
 Very Low
 Low
 Medium
 High
 Urgent
 Critical

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.
 Negligible
 Very Low
 Low
 Medium
 High
 Urgent
 Critical

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.
 Negligible
 Very Low
 Low
 Medium
 High
 Urgent
 Critical

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.
 Negligible
 Very Low
 Low
 Medium
 High
 Urgent
 Critical

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.
 Negligible
 Very Low
 Low
 Medium
 High
 Urgent
 Critical

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.
 Negligible
 Very Low
 Low
 Medium
 High
 Urgent
 Critical

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.
 Negligible
 Very Low
 Low
 Medium
 High
 Urgent
 Critical

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.
 Negligible
 Very Low
 Low
 Medium
 High
 Urgent
 Critical

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.
 Negligible
 Very Low
 Low
 Medium
 High
 Urgent
 Critical

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
 Up to 1000kv
 11KV
 22KV
 33KV
 66KV
 132KV
 220KV
 330KV

What plant Clearance is required for the identified voltage

What Is the Ground Approach Distance (GAD)
 Low Voltage = 1.5 meters
 High Voltage 1KV up to 33KV = 1.2 meters
 66KV = 1.5 meters
 132 KV = 1.5 meters
 132KV = 1.8 meters
 Over 132KV = 3 meters

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