Title Page

  • 1. This form must be completed each day at the first work site. New hazards identified that are NOT on the HAC relating to a specific task, must be recorded within the additional and significant hazards section.

  • 2. Complete a new form whenever conditions change I.E type of work site, work activities , significant Hazards.

  • Date:

  • Client Name:

  • Prepared by:

  • Location:
  • Photos of Job:

Emergency Management

  • Emergency Contact Number:

  • Evacuation Point / Assembly Area

  • First Aid Kit Location/s

    • In an emergency

    • Evacuate all persons on site to designated assembly area.

    • Lock down the site if possible

    • Contact Emergency Services

Roles & Responsibilities

  • PIC - Person in charge: I am responsible for conducting the crew risk assessment and ensuring that control measures are implemented by all crew Members

  • C/M - Crew Member: I am responsible for ensuring the safety of myself and others and adhering the Rick assessment.

  • V - Visitor: I am responsible for ensuring that I am briefed on the risk assessment and control plan, wear required PPE, adhere to control measures and follow all instructions.

Crew / Visitor Sign on - Required for every person entering the worksite.

  • Add drawing

  • Worker
  • Role:

  • Name:

  • Date:

PIC required information

  • PIC has confirmed verbally with all the crew onsite, that they have All the relevant licenses & white cards with them today.

  • If No, an incident report must be completed, and the person/s must leave the worksite immediately.

Job description & Work Procedures

  • List the main task that will be preformed on this site.

Task 1

  • Job Activities

  • List of swms in use for this job ( if applicable):

  • Have all relevant workers read the SWMS?

  • Have all the works been trained in the SWMS?

Hazard & Control Measures

  • Tick the boxes for the activities relevant to the work location/s. Ensure that specific risk control measures have Been put in place as per the safe work method statement (SWMS).

  • Write in any new hazards identified (i.e not stranded HAC) And significant hazards for the worksite. Write down control measures to be applied. If you cannot control hazard stop work and contact your supervisor.

  • Additional & Significant Hazards / Control Measures


Traffic Control Setup

  • Traffic Control Diagram/s used (TCP No.) :

Risk Assessment Matrix

  • HB 436:2004 Risk Management Guidelines Tables 6.3 – 6.8 reproduced with permission from SAI Global under licence 1210-c062. Standards may be purchased at http://www.saiglobal.com
    References: Safe Work Australia (2011) - Code of Practice: How to Manage Work Health and Safety Risks, AS/NZS 31000 -2009 Risk Management Principles and Guidelines.

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