Information
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Client / Site
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Conducted on
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Enter Date and Time:
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Step 1 - Initial Assessment - Ask yourself the following questions:
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Is mobile plant required for the task safe to operate?
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If the task involves the use of hazardous substances do you have the appropriate PPE?
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Check for potential exposure to energy sources (eg heat, power, air, hydraulics etc) - is is safe to commence work?<br>Check for overhead power lines.
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If the task involves excavation or trenching is it safe to commence work?
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For task conducted at height is it safe?
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Check prior to starting work if task interact with other plant/equipment, public or traffic - Is it safe to commence work?
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When working near/in waterways, protected vegetation, sensitive residences or heritage sites confirm safe to commence work?
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If you answer "No" to any of the questions above, you need to see your Supervisor to ensure a SWMS is developed prior to commencing work.
If you answered "Yes" to all or "N/A" proceed to Step 2 - Hazard/Issue Check -
Step 2 HAZARD/ISSUE CHECK
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I have completed STEP 1, and the SWMS that I have signed onto covers the task I'm about to do?
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I am trained and competent to undertake this task?
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I have the appropriate PPE to use for this task?
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There is safe access and egress to the work area?
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Appropriate controls to work at height are in place?
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I know what assistance I may need to lift materials?
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Check weather conditions will not impact on the environment or quality of works of my task - is it safe to commence work?
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Equipment for the task is tested/tagged and safe for use?
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The controls in place are appropriate to protect others around me, the environment and the work itself.
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Have you put out relevant safety signage & safety cones to ensure the site is safe for workers and public?
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I feel it is safe to conduct the task?
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If you answer "NO" to any of the above questions, then fix the hazard and/or inform your Supervisor immediately.
If you have answered "YES" or "N/A" to all of the questions then proceed to commencing the works. -
Staff Present
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I agree to comply with all requirements provided under my restricted duties
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I have notified my supervisor of any jobs outside of my suitable duties plan which I will not be able to complete
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I will not be on my feet for over 2 hours without resting
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I will not complete tasks with prolonged kneeling, squatting, crouching or walking for more than 30 minutes without positional change
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I will not lift more than 20kg
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I will not complete any harness work
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I will supervise other site staff to complete the tasks i am restricted from doing
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I will instruct staff members in a supervisory capacity only to complete tasks which fall under my restrictions
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I understand that it is my responsibility to fully comply with my restricted duties programe
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Terry Cullip
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