Information
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Client
- Queensland Urban Utilities
- Unity Water
- Watercorp
- Sydney Water
- City of Gold Coast Council
- Other
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Site / Project
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Conducted on
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Prepared By
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Location
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Enter address if not identified
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Line Segment
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Row # (If applicable)
Upstream Manhole Details
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Manhole Location
- Road
- Park
- Residential Yard
- Car Park
- Commercial Premisis
- Footpath
- Other
Downstream Manhole Details
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Is this section relevant?
Safety Conversation
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Safety Share/ Safety Alerts or L2BL communicated
- Road
- Park
- Residential Yard
- Car Park
- Commercial Premisis
- Footpath
- Other
Personnel Details
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Identified Workgroup
- Lining Crew
- Cutting Crew
- Dig Up Crew
- Cleaning Crew
- Subcontractor
- Other
- Interfit
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SNRP Details
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Interflow Worker(s) Details
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Contractor(s) Details
Work Pack Risk Assessment
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All roles and responsibilities have been identified and are understood?
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Work Pack has been completed in full consultation with all - includes Subcontractors i.e. Traffic Controllers?
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Work Method Statements have been correctly identified for the scope of work and can be validated as having been reviewed in full by all members of the work group
Identify any High Risk Work Activities and verify controls have been implemented adequately to mitigate RISK
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- Confined Space Entry
- Excavation and Trenching
- Electrical Safety
- Use of Hazardous Chemicals
- Working at Height
- Hazardous Manual Tasks - i.e. Lifting and Pulling
- Use of Plant and Equipment - i.e. Vehicle Loading Crane (VLC)
- Working Adjacent to the Roadway - Traffic Management
- Energy Isolation - Lock Out/ Tag Out
- Working Adjacent to Water
- Lone Worker
- Demolition Works
- Scaffolding
- Asbestos Removal or Handling
- Use of High Pressure Equipment
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Additional Notes on Implemented Controls
Photos
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Add media
Verification Completed by
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Full Name
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Full Name