Information

  • Client

  • Site / Project

  • Conducted on

  • Prepared By

  • Location
  • Enter address if not identified

  • Line Segment

  • Row # (If applicable)

Upstream Manhole Details

  • Manhole Location

Downstream Manhole Details

  • Is this section relevant?

Safety Conversation

  • Safety Share/ Safety Alerts or L2BL communicated

Personnel Details

  • Identified Workgroup

  • SNRP Details

  • Interflow Worker(s) Details

  • Contractor(s) Details

Work Pack Risk Assessment

  • All roles and responsibilities have been identified and are understood?

  • Work Pack has been completed in full consultation with all - includes Subcontractors i.e. Traffic Controllers?

  • 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

  • Additional Notes on Implemented Controls

Photos

  • Add media

Verification Completed by

  • Full Name

  • Full Name

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.