Title Page
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Job #
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Conducted on
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Prepared by
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Site Name
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Site Address
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Site Contact Name
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Site Contact Number
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Scope of Works
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Start Time
Risk Assessment
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Instructions
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1. Answer "Safe", "At Risk", "N/A" for each of the hazards below
2. If "At Risk", follow the questions to identify the likelihood of occurrence, severity and risk rating
3. Include any notes and photos by clicking on the paperclip icon and then "Add Image"
4. Answer the relevant control questions
5. Complete the form by providing the relevant signatures
Working in Confined Space
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Work in Confined Space
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Likelihood of occurrence
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Severity
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Risk Rating
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Working in Confined Space Permit received
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Enter description of control measures
Working at Height
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Working at Height
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Likelihood of occurrence
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Severity
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Risk rating
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Working at height permit received
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Height safety harness worn
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Enter description of control measures
Working on Ladders/Steps
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Working on Ladders/Steps
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Likelihood of occurrence
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Severity
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Risk rating
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Visually inspection of all access equipment
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Enter description of control measures
Working on or Near Electricity or Gas
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Electricity or Gas
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Likelihood of occurrence
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Severity
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Risk rating
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Enter description of control measures
Hazardous Gases / Compressed Air
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Hazardous Gases / Compressed Air
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Likelihood of occurrence
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Severity
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Risk rating
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Enter description of control measures
Slips, Trips and Falls
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Uneven/slippery Surfaces
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Likelihood of occurrence
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Severity
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Risk rating
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Enter description of control measures
Vibrating Hand Tools
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Vibrating Hand Tools
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Likelihood of occurrence
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Severity
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Risk rating
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Enter description of control measures
Asbestos
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Asbestos
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Likelihood of occurrence
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Severity
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Risk rating
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Enter description of control measures
Vehicular movement
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Vehicular movement
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Likelihood of occurrence
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Severity
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Risk rating
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Enter description of control measures
Dust, Fumes & Airborne particle's
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Dust, Fumes & Airborne particle's
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Likelihood of occurrence
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Severity
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Risk rating
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Enter description of control measures
Working over/near water
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Working over/near water
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Likelihood of occurrence
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Severity
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Risk rating
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Enter description of control measures
Overhead hazards
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Overhead hazards
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Likelihood of occurrence
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Severity
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Risk rating
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Enter description of control measures
Manual handling
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Manual handling
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Likelihood of occurrence
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Severity
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Risk rating
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Enter description of control measures
Working with Hazardous Chemicals
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Hazardous Chemicals
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Likelihood of occurrence
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Severity
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Risk rating
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Enter description of control measures
Noise
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Noise
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Likelihood of occurrence
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Severity
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Risk rating
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Enter description of control measures
Hot Works - Soldering Pipes or Joints
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Soldering Pipes or Joints
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Likelihood of occurrence
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Severity
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Risk rating
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Hot Works Permit received
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Enter description of control measures
Excavations/Buried/Covered services
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Excavations/Buried/Covered services
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Likelihood of occurrence
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Severity
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Risk rating
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Enter description of control measures
Lone worker
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Lone worker
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Likelihood of occurrence
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Severity
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Risk rating
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Enter description of control measures
Plant, Equipment and Handheld Tools
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Plant, Equipment and Handheld Tools
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Likelihood of occurrence
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Severity
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Risk rating
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Enter description of control measures
Completion
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Observations and recommendations
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Work completed
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Equipment is safe & fit to operate
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Customer representative
Method Statement
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List the sequence of tasks to complete scope of works
PPE - Select specific PPE to be worn as part of the works
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Hi Visibility Clothing
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Protective Footwear
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Protective Gloves
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Eye Protection
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Head Protection
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Ear Protection
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Protective Apron
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Respiratory Protection
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Disposable Mask
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Safety Harness
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Life Jacket
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Self Contained Breathing Appliances
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Protective Clothing
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Opaque Eye Protection
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Welding Mask
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Face Shield
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Other PPE
Welfare Assessment
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Will suitable welfare facilities be available to our staff (WC's)?
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Will safe drinking water be available to our staff?
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Will canteen facilities or nearby such facilities be available?
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Will first aid and eye wash facilities be available on site?
Job Notes
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Add before work photos
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Add completed photos
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Description of work completed
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Any Materials Purchased?
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Any Van Materials Used?
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Any Waste removed from site?
Completion
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Has the job been completed?
- Safe
- No - Requires Further Work
- No - Requires Quote
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Start Time
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Finish Time
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Operative Name
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Operative Signature
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Client Name
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Client Signature (Acknowledgement of works completed to standard)
