Information

  • Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

JOB SPECIFICS

  • WORKS ORDER DETAILS

  • Claim Number

  • For Hub

  • Requested By

  • Purchase Order Number

  • Works Order Number

  • The person in control of the job is :

  • The person in control of the job is :

  • CLIENT DETAILS

  • Owners Name

  • Owners Contact Details

  • Tenants Name

  • Tenants Contact Details

  • Access Details (who to call, key given or left etc)

INITIAL INSPECTION

  • BUILDING TYPE

  • The Building Is

  • The Building is on

  • Is the home in a damp environment?

  • Floor Area M2

  • Internal Stud Height M

  • Comments:

  • HEALTH ISSUES

  • Is respiratory distress common?

  • Are occupants suffering from asthma that has worsened?

  • Are occupants suffering nose bleeds?

  • Are occupants suffering headaches?

  • Do occupants suffer from itchy eyes?

  • Do occupants suffer from rashes and/or skin lesions?

  • Do occupants notice an improvement when they leave the home for a period of time?

  • Comments

  • PSYCHOMETRIC CONDITIONS

  • Outdoor Temperature

  • Ambient Outdoor RH%

  • Indoor Temperature

  • Indoor RH%

  • Sub Floor Temperature

  • Sub Floor RH%

  • Equilibrium RH%

  • Moisture Content is (WME%)

  • CAUSE OF WATER INTRUSION

  • Rising Damp

  • Is there rising damp due to earthquake (explain)

  • Is rising damp from liquefaction under the floor?

  • Presence of liquefaction is

  • Consistency of Liquefaction is:

  • Is mould present?

  • Is sewage present?

  • Is pungent Odour present?

  • Is there water intrusion to the building envelope due to liquefaction?

  • Would you recommend removal of liquefaction?

  • Leaking Water/Drain Pipe

  • Is Water intrusion due to a leaking pipe?

  • Has leak been fixed?

  • Was leak caused by a sudden event?

  • Where is/was leak?

  • Photo

  • Weather Penetration

  • Is water intrusion due to leak in roof or building envelope?

  • Has leak been fixed?

  • Was leak caused by a sudden event?

  • Where is/was leak?

  • Photo

  • MOULD INSIDE

  • What type of mould exists inside?

  • Where is the mould located?

  • Photo

  • Does mould need to be physically removed?

  • MOULD IN SUB FLOOR

  • What type of mould exists under floor?

  • Where is the mould located?

  • Photo

  • Does mould need to be physically removed?

  • REMEDIATION STRATEGY RECOMENDATIONS

  • ECC/AIR IMPACT Testing of recommended?

  • Samples Taken?

  • Sample taken by:

  • Pre works 'make safe' subfloor decontamination recommended?<br> (Basic treatment to ensure the health and safety of tradesmen working in the area)

  • Pre works 'make safe' internal decontamination recommended?<br> (Basic treatment to ensure the health and safety of tradesmen working in the area)

  • Removal of Liquefaction Recomended?<br> (observations, access etc)

  • Mechanical drying of underfloor most likely required?<br> (estimated timeframe if known)

  • Placement and/or replacement of DPM in subfloor?

  • Physical removal of mould most likely required?

  • Mechanical drying inside home most likely required?<br> (estimated timeframe if known)

  • Post works FULL subfloor decontamination recommended?<br> (include notes re drying required etc)

  • Post works FULL internal decontamination recommended?<br> (include notes re drying required etc)

  • CONCLUSION

  • Recommended PPE Requirements prior to/or without 'make safe' decontamination treatment

  • Recommended PPE Requirements prior to/or without Full decontamination treatment

  • Recommended PPE Requirements post 'make safe' decontamination treatment

  • Recommended PPE requirement post FULL decontamination treatment

  • Comments

  • Quote for Recommended Remediation Provided?

SITE SPECIFIC SAFETY PLAN

1. WORKPLACE CONTROL AND HEALTH AND SAFETY MANAGEMENT

  • The on-site safety representative (SR) for this project is

  • The person in control of the workplace is :

2. NOTIFIABLE WORKS

  • We have Notifiable Works associated with our subcontract

  • DoL will be advised of Notifiable Works upon acceptance of quote

3. HAZARD MANAGEMENT

  • We will maintain an onside Hazard Register of all existing and new hazards and appropriate controls

  • We will prepare a written Task Analysis covering all significant hazards associated with our works, in conjunction with employees, and give it to site management before any work involving that hazard commences onsite

  • Are there hazardous products/processes associated with our subcontract works?

  • Appropriate Safety Data Sheets have been supplied to the main contractor?

  • Appropriate Safety Data Sheets have been are available on site?

4. COMMUNICATION/EMPLOYEE PARTICIPATION

  • The methods we use to communicate safety information to our employees are:

  • Daily Toolbox Talks - including covering site hazards and emergency/evacuation procedures

  • Monthly Health and Safety Meetings - covering use of equipment, hazards encountered

  • Pre-task Planning Meetings - Done first Visit to site post quote approval

  • Co-ordination Meetings

  • Other

  • Urgent Safety Updates are e-mailed and/or TXT to all staff and put on the router for the next Health and Safety Meeting

5. EMERGENCIES

  • Emergency Kit One (First Aid Kit, Confined space emergency kit, Fire Extinguisher) is located

  • Emergency Kit Two (First Aid Kit, Confined space emergency kit, Fire Extinguisher) is located

  • We have trained First Aid personnel and procedures in place on site to render assistance in the event of an accident/emergency

  • Our Designated Warden/First Aid person is

  • In the event of a site emergency or evacuation our personnel will report to our safety representative and assemble at the evacuation area shown on the Emergency Evacuation Plan

  • We have an Emergency Plan for all hazardous products and processes referred to in section 3 above

  • EMERGENCY PLAN AND PROCEDURES FOR HAZARDOUS WORK

  • Emergency Procedure: Evacuate to meeting point specified below, Role call, Dial 111 Emergency Services and/or administer First Aid if required

  • Evacuation Plan for all Emergency Situations: Alarm Evacuation, Unsound Building, Earthquake, Fire, Tsunami, Other

  • Evacuation Plan 3: Other

6. ACCIDENT/INCIDENT: REPORTING/INVESTIGATION/RECORDING

  • We have an accident/incident reporting/investigation system in place and keep an Accident/Incident Register

  • We will immediately notify all serious harm accidents to site management and follow up within 7 days with a completed copy of the Accident and Incident Investigation Report

7. SAFETY INSPECTIONS AND SAFETY REVIEWS

  • We agree to undertake safety inspections and reviews at the intervals required by the Safety Activity Monitoring Register Wall Chart

  • A sample of documentation of our safety inspections has been sent to the main contractor

8. TRAINING/INDUCTION

  • All persons under our control hold current passports or induction pass cards as required

  • All persons under our control on site are given a site specific safety induction

  • All persons under our control on site are appropriately qualified, competent or fully supervised

9. SUBCONTRACTORS

  • Will we have subcontractors working for you on this project

  • Subcontractors to provide SSSP

  • Subcontractors to provide Task Analysis

SIGNATURE

  • Signature of Technician Compiling SSSP

  • Time and date Task Analysis Complete

TASK ANALYSIS

  • GENERAL STEPS

  • Step 1: Assess property for external hazards

  • Step 2: Familiarise customer with process and requirements

  • Step 3: Erect signs and barricades and/or check existing signs and barricades

  • Potential Hazard:

  • Control Methods:

  • Step 4: Don PPE according to task requirements as below

  • ---------------------------------------------------------------------------------------------------------------------------------------------------------

  • Step 5: As per task below

  • ---------------------------------------------------------------------------------------------------------------------------------------------------------

  • Step 6: Remove PPE

  • Potential Hazard:

  • Control Methods

  • Step 7: Ensure any signage being left onside is secure and visible

  • Step 8: Remove signage not being left onsite

  • Step 9: Check site and leave

  • ECC AND/OR AIR SAMPLING

  • A) Follow steps 1-4 of general

  • B) Load in equipment

  • Potential Hazard:

  • Control Methods:

  • C) Record observations including clients comments

  • D) Take samples as required

  • Potential Hazard:

  • Control Methods:

  • E) Follow steps 6-9 of general

  • DECONTAMINATION OF CRAWL SPACE

  • A) Follow steps 1-4 of general

  • B) Ensure all occupants and pets are out of the area to be decontaminated

  • Potential Hazard:

  • Control Methods:

  • C) Block all foundation vents

  • D) Load in equipment

  • Potential Hazard:

  • Control Methods:

  • E) Load in disinfectants and ensure they are safely stored and mixed

  • Potential Hazard

  • Control Methods

  • F) Treat Subfloor

  • Potential Hazard:

  • Control Methods:

  • G) Follow steps 6-9 of general

  • DECONTAMINATION OF INTERNAL ENVELOPE OF PROPERTY

  • A) Follow steps 1-4 of general

  • B) Load in equipment

  • Potential Hazard:

  • Control Methods:

  • C) Load in disinfectants and ensure they are safely stored and mixed

  • Potential Hazard

  • Control Methods

  • D) Take pre-air samples

  • Potential Hazard:

  • Control Methods:

  • E) Ensure all occupants and pets are out of the area to be decontaminated

  • Potential Hazard:

  • Control Methods:

  • F) Apply surface treatments

  • G) Set VHP and close up home

  • H) Follow steps 6-9 of general

  • POST TREATMENT SAMPLING

  • A) Follow steps 1-4 of general

  • B) Upon Re-entry, test VHP levels. Only re-enter if safe to do so

  • Potential Hazard:

  • Control Methods:

  • C) Take Post Samples

  • Potential Hazard:

  • Control Methods:

  • Signature of Technician Compiling Task Analysis

  • Time and date Task Analysis Complete

CHECKLIST

  • Initial inspection report complete?

  • SSSP Complete?

  • Task analysis complete?

  • Quote complete

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.