LDCO - JSA Domestic - Site Specific Risk Assessment

• Job Title

• Client / Site

• Document No.

• Location
  Address

• Conducted on

  Date

• Prepared by

  Sign

• Personnel

JOB

• Job Category

  Select New Installation Repair Other

  • New Installation
  • Repair
  • Other

• Description

• Job Type

  Select Light Powerpoint Fan AC Hot water Sensor Switchboard Circuit Other

  • Light
  • Powerpoint
  • Fan
  • AC
  • Hot water
  • Sensor
  • Switchboard
  • Circuit
  • Other

• Description

HAZARDS

• Powered Tools

• Falls

• Manual Handling

• Confined Spaces

• Live Parts

• Lone Worker

• Ladders

• Excavation

  Off

  On

• Falling Objects

  Off

  On

• Moving plant

  Off

  On

• Noise

  Off

  On

• Access / Egress

  Off

  On

• Asbestos

  Off

  On

• Working in Trenches

  Off

  On

• Dust

  Off

  On

• Scaffolding

  Off

  On

• UV radiation

  Off

  On

• Other

  Off

  On

• Other hazard:

SWMS

• Working on or near Exposed Energized Electrical Equipment

• Heights

• Confined Spaces

• Working Near Overhead Powerlines

  Off

  On

• Plant

  Off

  On

• Excavation and Trenching

  Off

  On

• Asbestos

  Off

  On

• Hazardous Substances

  Off

  On

• Demolition

  Off

  On

• Working on or near a road

  Off

  On

PROCEDURES

• Live testing

• PPE Management

• Risk Management and Hazard Intervention

• Visual Safety Examination Inspection

• Ladders

• Electrical safety (general)

• Inspection of safety equipment

• Isolation Safety Tag and Lockout

• Testing of Electrical Equipment and Installation

• Manual Handling

• Work on Electrical Equipment

• Heights

• Heights Rescue

• Emergency Preparedness

• CCICR (ceiling, crawling & conductive roofs)

• Housekeeping

• Noise Management

  Off

  On

• Plant and Equipment

  Off

  On

• Working in the sun

  Off

  On

• Testing and Tagging

  Off

  On

• Accessing a Pit or Pillar

  Off

  On

• Hazardous Substances Management

  Off

  On

• Working in the Vicinity of Exposed Live Parts

  Off

  On

• Excavation and Trenching

  Off

  On

• Safe working with Asbestos

  Off

  On

LiCENCES AND EQUIPMENT

• Competency Records / Licences

  Select electrical licence white card or equivalent scaffold > 3m erection licence EWP / Boom >11m lift licence other

  • electrical licence
  • white card or equivalent
  • scaffold > 3m erection licence
  • EWP / Boom >11m lift licence
  • other

• High Risk Plant / Equipment being used

  Select EWP / Boom Lift >11m Scaffold Scissor Lift Forklift EWP Boom Lift <11m Excavator Hiab / Crane Other

  • EWP / Boom Lift >11m
  • Scaffold
  • Scissor Lift
  • Forklift
  • EWP Boom Lift <11m
  • Excavator
  • Hiab / Crane
  • Other

• Other:

RISK ASSESSMENT

Task

• Task details

• Hazards and Risks

• Initial Risk Level

  Low

  Controlled

  High

• Controls undertaken to minimise risk:

• Residual Risk Level

  Low

  Controlled

  High

• Risk Likelihood Matrix

  

• Risk Decision Tree

  

• If the residual risk is High or Catastrophic, permission must be sought by High Level Management for work to proceed.

• Is the residual risk High or Catastrophic?

  Yes

  No

• You must contact High Level Management before continuing.

CERTIFICATION

• I certify that the above control measures have been implemented and deemed the site to be safe:

  Sign

• Additional workers:

  Sign

• Additional workers:

  Sign