• 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

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