Information
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Prepared by
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Assessment Date
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Job
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Is task being completed by contractor or their sub contractor?
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Contractor Company name
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Contact Phone Number
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If contractor supplies JSA ,upload here
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Is the contractor JSA uploaded?
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Is it comprehensive enough and have all risks been sufficiently managed?
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Describe task
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What is the hazard Type/s? Select as many as apply Physical, e.g. moving vehicles, falling objects, stairwells Environmental, e.g. chemical exposure, extreme temperature, noise, weather Chemical, e.g. ammonia, gas Biological, e.g. fungus, virus, legionnaire’s disease Psychological e.g. stress, fatigue, relationships Ergonomic e.g. work station, equipment, locations of task and users
- Physical
- Environmental
- Chemical
- Biological
- Psychological
- Ergonomic
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Add media
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Does the work involve lone worker assessment?
Enter Control Measures
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Add media
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Assigned Workers
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Is a plant or equipment shut down required?
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What plant or equipment will shut down
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Time and Date
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Total hours expected to be shut down
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Authorised by (enter name of Branch Manager when any impact on stores, or Engineering manager)
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Procedure if this time is exceeded
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Working in roof-space within 2m of edge and beyond safety barriers?
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Working at heights training has been completed?
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Sufficient safety measures/fall restraint to be used?
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CSN Induction for roof space completed?
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Permit to Work Required?
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Enter Permit details
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or upload permit
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Describe task
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What is the hazard Type/s? Select as many as apply Physical, e.g. moving vehicles, falling objects, stairwells Environmental, e.g. chemical exposure, extreme temperature, noise, weather Chemical, e.g. ammonia, gas Biological, e.g. fungus, virus, legionnaire’s disease Psychological e.g. stress, fatigue, relationships Ergonomic e.g. work station, equipment, locations of task and users
- Physical
- Environmental
- Chemical
- Biological
- Psychological
- Ergonomic
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Add media
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Does the work involve lone worker assessment?
Enter Control Measures
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Add media
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Assigned Workers
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Is task being completed by CSN staff?
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Describe task
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What is the hazard Type/s? Select as many as apply Physical, e.g. moving vehicles, falling objects, stairwells Environmental, e.g. chemical exposure, extreme temperature, noise, weather Chemical, e.g. ammonia, gas Biological, e.g. fungus, virus, legionnaire’s disease Psychological e.g. stress, fatigue, relationships Ergonomic e.g. work station, equipment, locations of task and users
- Physical
- Environmental
- Chemical
- Biological
- Psychological
- Ergonomic
-
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-
-
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Add media
-
Does the work involve lone worker assessment?
Enter Control Measures
-
Add media
-
Assigned Workers
-
Is a plant or equipment shut down required?
-
What plant or equipment will shut down
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Time and Date
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Total hours expected to be shut down
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Authorised by (enter name of Branch Manager when any impact on stores, or Engineering manager)
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Procedure if this time is exceeded
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Working in roof-space within 2m of edge and beyond safety barriers?
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Working at heights training has been completed?
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Sufficient safety measures/fall restraint to be used?
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CSN Induction for roof space completed?
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Permit to Work Required?
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Enter Permit details
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or upload permit
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Task Review
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Completion Date
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Has Review of Task been completed?
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Review Date
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Was the task completed safely?
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Confirm that unsafe actions have been raised in Vault
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Has area been cleaned and fit for use again.
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Describe actions taken to clean and make area fit for use again
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Reviewed by
