Lone Working Policy Template

• Site

• Conducted on

  Date

• Prepared by

• Lone Worker

• Location
  Address

Lone Working Policy

• Policy Statement

• Scope

• Related Policies and Procedures

• Context

• Potential Hazards of Working Alone

• Control Measures to reduce the risk

  Select Elimination Substitution Engineering Controls Administrative Controls PPE

  • Elimination
  • Substitution
  • Engineering Controls
  • Administrative Controls
  • PPE

• Application of control measures

• Supervision

• Emergency protocols

• Recommendations / Conclusion

Completion

• The above statement has been discussed and both parties agrees with all the clauses mentioned above.

• Lone Worker (Name and Signature)

  Sign

• Approved by (Name and Signature of Officer in charge)

  Sign