Information

  • Client / Site

  • Conducted on

  • Enter Date and Time:

  • Step 1 - Initial Assessment - Ask yourself the following questions:

  • Is mobile plant required for the task safe to operate?

  • If the task involves the use of hazardous substances do you have the appropriate PPE?

  • 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.

  • If the task involves excavation or trenching is it safe to commence work?

  • For task conducted at height is it safe?

  • Check prior to starting work if task interact with other plant/equipment, public or traffic - Is it safe to commence work?

  • When working near/in waterways, protected vegetation, sensitive residences or heritage sites confirm safe to commence work?

  • 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

  • I have completed STEP 1, and the SWMS that I have signed onto covers the task I'm about to do?

  • I am trained and competent to undertake this task?

  • I have the appropriate PPE to use for this task?

  • There is safe access and egress to the work area?

  • Appropriate controls to work at height are in place?

  • I know what assistance I may need to lift materials?

  • Check weather conditions will not impact on the environment or quality of works of my task - is it safe to commence work?

  • Equipment for the task is tested/tagged and safe for use?

  • The controls in place are appropriate to protect others around me, the environment and the work itself.

  • Have you put out relevant safety signage & safety cones to ensure the site is safe for workers and public?

  • I feel it is safe to conduct the task?

  • 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

  • I agree to comply with all requirements provided under my restricted duties

  • I have notified my supervisor of any jobs outside of my suitable duties plan which I will not be able to complete

  • I will not be on my feet for over 2 hours without resting

  • I will not complete tasks with prolonged kneeling, squatting, crouching or walking for more than 30 minutes without positional change

  • I will not lift more than 20kg

  • I will not complete any harness work

  • I will supervise other site staff to complete the tasks i am restricted from doing

  • I will instruct staff members in a supervisory capacity only to complete tasks which fall under my restrictions

  • I understand that it is my responsibility to fully comply with my restricted duties programe

  • Terry Cullip

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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.