REPORT

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
The Occupants suffer from

Anyone of Specific Concern? (Name)

Is there anything in their personal room that one could attribute their problems to?

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

Description of Other

Comments

PSYCHOMETRIC CONDITIONS

Outdoor Temperature

Ambient Outdoor RH%

Indoor Temperature

Indoor RH%

Sub Floor Temperature

Sub Floor RH%

Equilibrium RH%

Moisture Content is (WME%)

ISSUE

Description of the problem

Problems Identified
Mould is located....

MOULD INSIDE

Where inside is the mould located?

What type of mould exists inside?

Does mould need to be physically removed?

Samples Taken?

Date Report Expected Back
Photo

MOULD IN SUB FLOOR

Where in the subfloor is the mould located?

What type of mould exists under floor?

Does mould need to be physically removed?

Samples Taken?

Date Report Expected Back
Photo

OTHER

Where is the mould located?

What type of mould exists?

Does mould need to be physically removed?

Samples Taken?

Date Report Expected Back
Photo

SEWERAGE CONTAMINATION

Where is the possible Sewerage located?

Does it need to be physically removed?

Samples Taken?

Date Report Expected Back
Photo

PUNGENT ODOUR CONTAMINATION

Where is the pungent odour located?

Can you identify the source of the odour?

Does it need to be physically removed?

Samples Taken?

Date Report Expected Back
Photo

OTHER CONTAMINATION

Describe the contamination

Where is the contamination located?

Can you identify the source of the contamination?

Does it need to be physically removed?

Samples Taken?

Date Report Expected Back
Photo

Comments

POSSIBLE CAUSE
POSSIBLE CAUSE OF THE PROBLEM

Liquefaction

Presence of liquefaction is

Consistency of Liquefaction is:

Is liquefaction causing increased moisture levels?

Would you recommend the removal of liquefaction? (Explain)

Rising Damp

Suspected cause of rising damp

Has the cause been fixed yet?

Explain/Describe/Photograph Cause

Water Intrusion

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

Was leak caused by a sudden event?

Where is/was leak?

Has leak been fixed?

Photo

Leaking Water/Drain Pipe

Was leak caused by a sudden event?

Where is/was leak?

Has leak been fixed?

Photo
REMEDIATION STRATEGY RECOMENDATIONS

ECC/AIR IMPACT Testing of recommended?

Samples Taken?

Recommended PPE BEFORE or without decontamination treatment
Pre works 'make safe' decontamination recommended for.... (Basic treatment to ensure the health and safety of tradesmen working in the area)
Recommended PPE AFTER 'make safe' decontamination treatment
Mechanical drying most likely required for.... (estimated timeframe if known)

Estimated Timeframe for drying....

Removal of Liquefaction Recomended?
(observations, access etc)

Placement and/or replacement of DPM in subfloor recommended?

Physical removal of mould most likely required? (Describe)

Post works FULL decontamination recommended for.... (Basic treatment to ensure the health and safety of the occupants)
Recommended PPE AFTER 'FULL' decontamination treatment
CONCLUSION

Comments

SSSP

ABOUT THE SSSP

- This SSSP is unique to each site being worked on. It is to be completed by the accreditation contractor prior to the commencement of work and submitted, along with the quote, for acceptance.
- The SSSP is a live document and must be updated during the work process to address changes to site hazards and workers on the site.
- The occupants of the property must be inducted into the SSSP. Occupants who are relocating off-site during the repair work must be advised of all precautions they must take if they return to their home at any time during the repair process.

1.0 SITE REQUIREMENTS

Site Specific Safety Plan

Location of SSSP Onsite

Description of Other Location

Site Evacuation Plan (copy attached)

Location of Evacuation Plan Onsite

Description of Other Location

Site Hazard Register (copy attached)

Location of Hazard Register Onsite

Description of Other Location

Site Induction Register to be used?
Location Induction Register Onsite

Description of Other Location

Site Hazard Board to be used?

Location of Hazard Board Onsite

Description of Other Location

Site Sign-In Sheet to be used?

Location of Sign-In Sheet Onsite

Description of Other Location

First Aid Kit Located Onsite

Location of First Aid Kit Onsite

Description of Other Location

Fire Extinguisher Located Onsite

Location of Fire Extinguisher Onsite

Description of Other Location

Any Council Permits Required

List of permits Required

Hazardous Substances used on site?

Location of SDS Onsite

Location Onsite

Description of Other Location

Description of Other Location

All hazardous substances listed on Haz. Register

2.0 HIGH RISK WORK

- If High Risk work is being undertaken then a Task Analysis must be submitted for each high risk job.
- All persons involved in High Risk must have received instruction and have read and understood the relevant Task Analysis, and be competent to complete the task they are assigned.

1. Friable asbestos work being carried out?

Task Analysis Attached?

2. Non-Friable asbestos work being carried out?

Task Analysis Attached?

3. Major Demolition work being carried out?

Task Analysis Attached?

4. Use of elevating work platforms required?

Task Analysis Attached?

5. Any working on roofs required?

Task Analysis Attached?

6. Work in confined or restricted spaces required?

Task Analysis Attached?

7. Work within 4.0m of overhead power lines?

Task Analysis Attached?

8. Is there any other high risk work?

Description of a High Risk work

Task Analysis Attached?

3.0 NOTIFIABLE WORK

Work defined by the MBIE Labour Group as 'Notifiable Work' (including 'Restricted Work') must be notified to the Labour Group by the Contractor using the appropriate documents.

Any Notifiable Work being carried out?

Has MBIE Labour Group been notified?

4.0 ACKNOWLEDGEMENT OF RESPONSIBILITIES

1. I confirm that all employees and sub-contractors to be working on site will have completed an induction course and will be in possession of a valid Identification Card.
2. I confirm all staff and sub-contractors working on site will be informed of the site rules (EQR Rules).
3. I confirm Tool Box Talks will be carried out and all Safety Alerts communicated to staff and sub-contractors.
4. I confirm that all persons on site will be competent to complete assigned tasks or will be fully supervised by someone who is.
5. I am aware of the hazards identified on this site and of my responsibilities to identify any additional hazards and take all practicable steps to eliminate, isolate or minimise those hazards.

Person Completing SSSP
Date

HIGH RISK WORK TASK ANALYSIS

High Risk Works being carried out (Not already covered in General Task Analysis)
ASBESTOS

Does MBIE Labour Group need to be notified?

Specialist Asbestos Task Analysis has been compiled

refer to General Task Analysis for details on common tasks

MAJOR DEMOLITION WORK

Does MBIE Labour Group need to be notified?

TASK ANALYSIS STEPS

Step

Description of Step

For this step I could

Which Control Method I will use (describe how, photo if possible)

refer to General Task Analysis for details on common tasks

USE OF ELEVATING WORK PLATFORMS

Does MBIE Labour Group need to be notified?

TASK ANALYSIS STEPS

Step

Description of Step

For this step I could

Which Control Method I will use (describe how, photo if possible)

refer to General Task Analysis for details on common tasks

WORKING ON ROOFS

Does MBIE Labour Group need to be notified?

TASK ANALYSIS STEPS

Step

Description of Step

For this step I could

Which Control Method I will use (describe how, photo if possible)

refer to General Task Analysis for details on common tasks

WORKING IN CONFINED/RESTRICTED SPACE

Does MBIE Labour Group need to be notified?

TASK ANALYSIS STEPS

Step

Description of Step

For this step I could

Which Control Method I will use (describe how, photo if possible)

refer to General Task Analysis for details on common tasks

WORKING WITHIN 4.0M OF OVERHEAD POWERLINES

Does MBIE Labour Group need to be notified?

TASK ANALYSIS STEPS

Step

Description of Step

For this step I could

Which Control Method I will use (describe how, photo if possible)

refer to General Task Analysis for details on common tasks

OTHER HIGH RISK WORK

Does MBIE Labour Group need to be notified?

OTHER HIGH RISK WORK

HIGH RISK WORK

Brief Description of High Risk Work

TASK ANALYSIS STEPS

Step

Description of Step

For this step I could

Which Control Method I will use (describe how, photo if possible)

refer to General Task Analysis for details on common tasks

GENERAL TASK ANALYSIS

DAILY

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

STEP 4: Don PPE according to task requirements as below

TASK SPECIFIC

STEP 5: Follow steps as required by job tasks

Tasks Associated with this job
ECC AND/OR AIR SAMPLING TASK ANALYSIS

A) Use Equipment as required
Potential Hazards: Electrical Hazards
Control Methods: Minimise - Ensure all items are used through RCDs and have current electrical tags.

B) Record observations including any clients comments

C) Take samples as required
Potential Hazard: Samples may need to be taken in confined spaces and/or contaminated zones
Control Methods: Minimise - Ensure required PPE is worn, there is more than one person onsite and
emergency tools are close at hand. If in confined space refer to

D) Ensure correct signage being left onsite for this step is secure and visible

SUB-FLOOR DECONTAMINATION TREATMENT TASK ANALYSIS

A) Ensure all occupants and pets are out of the area to be decontaminated
Potential Hazard: Pets/animals often claim shelter under houses and can be adversely
affected by treatment
Control Methods: Eliminate - Ask occupants to remove the animals from the property/area
while treatment is in progress. Check area to ensure none
remain, board up access points so other animals cannot enter
while treatment is in progress

B) Block all foundation vents

C) Load in equipment
Potential Hazard: Electrical Hazard
Control Methods: Isolate/Minimise - Ensure all items are used through RCDs and
have current electrical tags. Make sure cords
are not across walkways where possible.

D) Load in disinfectants and ensure they are safely stored and mixed
Potential Hazard: Spillages, accidental mixing (chemical cocktail)
Control Method: Minimise - Only remove from the van products that are
required at any one time. Ensure they are stored
and put away from any other products in the property

E) Treat Subfloor
Potential Hazard: Treatment is generally in a confined and contaminated zone
Control Methods: Minimise - Ensure there is more that one person onsite,
emergency tools are close at hand and required
PPE is worn

F) Ensure correct signage being left onsite for this step is secure and visible

DECONTAMINATION OF INTERNAL ENVELOPE

A) Take samples as required
Potential Hazard: Samples may need to be taken in confined spaces and/or contaminated zones
Control Methods: Minimise - Ensure required PPE is worn, there is more than one person onsite and
emergency tools are close at hand. If in confined space refer to

B) Ensure all occupants and pets are out of the area to be decontaminated
Potential Hazard: Pets/animals often claim shelter under houses and can be adversely
affected by treatment
Control Methods: Eliminate - Ask occupants to remove the animals from the property/area
while treatment is in progress. Check area to ensure none
remain, board up access points so other animals cannot enter
while treatment is in progress

C) Load in equipment
Potential Hazard: Electrical Hazard
Control Methods: Isolate/Minimise - Ensure all items are used through RCDs and
have current electrical tags. Make sure cords
are not across walkways where possible.

D) Load in disinfectants and ensure they are safely stored and mixed
Potential Hazard: Spillages, accidental mixing (chemical cocktail)
Control Method: Minimise - Only remove from the van products that are
required at any one time. Ensure they are stored
and put away from any other products in the property

E) Apply surface treatments

F) Set VHP and close up home

G) Ensure correct signage being left onsite for this step is secure and visible

H) Upon re-entry, test VHP levels. Only re-enter if daft to do so
Potential Hazard: Someone enters before it has been deemed safe
Control Methods: Ensure correct hazard signs are on all entry points
and if in doubt wear correct PPE

PHYSICAL CONTAMINATION REMOVAL

A) Take samples as required
Potential Hazard: Samples may need to be taken in confined spaces and/or contaminated zones
Control Methods: Minimise - Ensure required PPE is worn, there is more than one person onsite and
emergency tools are close at hand. If in confined space refer to

B) Ensure contaminated material is disposed of in the correct manner
Potential Hazard: Cross-contamination or contamination spreading
Control Methods: Isolate - Ensure contaminated material is contained and
disposed of in the correct manner.

C) Ensure correct signage being left onsite for this step is secure and visible

JOB COMPLETION

STEP 6: Remove signage not being left onsite

STEP 7: Check site and leave

JOB SPECIFICS

WORKS ORDER DETAILS

Claim Number

For Office (Hub)

Requested By

Site Supervisor (Case Manager)

Purchase Order Number

Works Order Number

CLIENT DETAILS

Property is

Owners Name

Owners Contact Details

Tenants Name

Tenants Contact Details

Person to contact for access

Access Details (who to call, key given or left, where lockbox location will be etc)

SITE EVACUATION PLAN

EMERGENCY RESPONSE PLAN

In the event of an emergency requiring the shutdown and/or evacuation of the site the following procedure will apply:
1. Notify all persons on site of the emergency.
2. Shutdown all plant and equipment.
3. Proceed immediately to the designated safe assembly point by the safest identifiable route.
4. Remain at the Assembly Point until all persons are accounted for.
5. Do not return to the work site unless authorised by emergency services and/or site supervisor.

In the event of an emergency the SITE SUPERVISOR or designated safety person shall:
1. Ensure all persons are accounted for.
2. Ensure Emergency Services have been called if required.
3. Ensure somebody is assigned to meet emergency services.
4. Notify Main Contractor of the emergency and liaise with Contracts Supervisor as required.
5. Liaise with Emergency Services and Contracts Supervisor prior to returning to work.
6. Ensure the site is safe prior to returning to work.

REPORTING OF INCIDENTS

- All accidents and incidents (events that resulted in or may have resulted in injury or illness) must be reported to Main Contractor and recorded.
- All serious harm and serious near-hits must be fully investigated.
- All serious harm injuries must be reported to the MBIE Labour Group and Main Contractor as soon as possible and within 1 hour.

EMERGENCY CONTACT DETAILS

POLICE FIRE AMBULANCE 111

NEAREST MEDICAL CENTRE

SERIOUS HARM MBIE Labour Group 0800 20 90 20

SPILLS/POLLUTION Environment Canterbury 03 366 4663 (ChchResidential) 0800 75 55 88 (Canterbury Area)

POISONING National Poisons Centre 0800 76 46 66

ANIMAL CONTROL CCC Dog Control 03 941 8999

POWER SUPPLY ISOLATION Orion 0800 363 9898

INITIAL SITE HAZARD REGISTER

The following Hazards have been identified on this site. It is the responsibility of all persons involved with this job to identify any new hazards that may be introduced during the course of the work and to ensure they are added to the register.

POTENTIAL HAZARD OR RISKS (Hazard or Risk Identified)

HAZARD

DESCRIPTION OF POTENTIAL HAZARD OR RISK

IS THIS A SIGNIFICANT HAZARD (Y/N)

METHOD OF HAZARD CONTROL (Describe)

RESPONSIBILITY (Person/s responsible for ensuring controls are implemented)

SITE HAZARD REGISTER

The following Hazards have been identified on this site. It is the responsibility of all persons involved with this job to identify any new hazards that may be introduced during the course of the work and to ensure they are added to the register.

HAZARD

POTENTIAL HAZARD OR RISK (Hazard or Risk Identified)


SIGNIFICANT HAZARD (Y/N)

METHOD OF HAZARD CONTROL (Eliminate, Isolate, Minimise)

DESCRIPTION OF METHOD OF HAZARD CONTROL


RESPONSIBILITY (Person/s responsible for ensuring controls are implemented)


HAZARD

POTENTIAL HAZARD OR RISK (Hazard or Risk Identified)


SIGNIFICANT HAZARD (Y/N)

METHOD OF HAZARD CONTROL (Eliminate, Isolate, Minimise)

DESCRIPTION OF METHOD OF HAZARD CONTROL


RESPONSIBILITY (Person/s responsible for ensuring controls are implemented)


Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.