M-BM-02-31 PRESTART SITE ASSESSMENT FORM

• This pre-start is a tool to assist workers in identifying workplace hazards prior to undertaking their tasks. All workers are to complete this form in full and ensure that hazards are identified, and controlled to as low as reasonably practicable. If workers are unable to implement control measures, please contact your line leader immediately.

• Date

  Date

• Work order #

• Person/s in control of worksite

• Work site location
  Address

Hazard identification - Complete prior to undertaking work

• Working on or adjacent to a road or railway*

  Yes

  No

• Movement of powered mobile plant*

  Yes

  No

• Airborne contaminants ie. Silica, paint fumes, exhaust fumes etc

  Yes

  No

• Working in a contaminated or flammable atmosphere ie. Confined spaces*

  Yes

  No

• Risk of falling more than 2m* including excavations, trenches, roof tops etc

  Yes

  No

• Risk of falling less than 2m including excavations, trenches, roof tops etc

  Yes

  No

• Working with asbestos*

  Yes

  No

• Working on or near energised electrical services such as overhead, underground and concealed services*

  Yes

  No

• Use of hazardous substances

  Yes

  No

• Risk of projectiles, which could cause an eye injury

  Yes

  No

• Hot works, such as grinding, oxy cutting, butane torch etc.

  Yes

  No

• Work that involves the risk of drowning*

  Yes

  No

• Working on scaffold

  Yes

  No

• Working on or near chemical, gas mains or piping*

  Yes

  No

• Demolition work*

  Yes

  No

• Vehicle loading crane (VLC)

  Yes

  No

• Members of the public (threatening work environment)

  Yes

  No

• Remote or isolated work (lone worker, no reception etc)

  Yes

  No

• Outdoor work/fatigue

  Yes

  No

• Manual tasks/handling

  Yes

  No

• Slips, trips and falls

  Yes

  No

• Excessive noise

  Yes

  No

• Vehicles, cyclists, e-scooter

  Yes

  No

• Vulnerable workers ie. Young or new (apprentice/inexperienced)

  Yes

  No

• Sewer, effluent, dirty places ie. toilet blocks, grease traps etc

  Yes

  No

• Needle sticks and sharps

  Yes

  No

• Electromagnetic Frequency EMF

  Yes

  No

• Ground penetrating activities ie. Excavating, installing star pickets, trenching etc

  Yes

  No

• Hand, power tools or other minor plant

  Yes

  No

• Falling objects

  Yes

  No

• Working in inclement weather

  Yes

  No

High Risk Work on site

• T&I QMS Safe Work Method Statements must be accessible on site

• T&I QMS Safe Work Method Statement numbers

• Additional hazards, risk and control measure not already identified

• What additional hazards were identified, and what control measures were implemented?

  Yes

  No

  N/A

BM QMS Work Instruction in use for activities on site

• BM outdoor work M-BM-03-01

• BM indoor work M-BM-03-02

• Playground inspection and maintenance M-BM-03-04

Emergency plan and response for this site

• Discuss with all workers on site

  Yes

  No

  N/A

Items to check

• Copies of Works Procedures, Risk Assessments, QMS Safe Work Method Statements and Traffic Management Plans for the above listed activities have been presented to and discussed with all employees and contractors involved in the works and are available on site for review

  Yes

  No

  N/A

• Any site-specific hazards identified that are not found in QMS Safe Work Method Statements or Risk Assessments have been discussed and control measures introduced?

  Yes

  No

• Relevant documentation and permits (DBYD, GCRT, Confined Space Entry, Hot Works) completed?

  Yes

  No

• All personnel operating plant or equipment have the correct licences/qualifications to operate such equipment and are competent in the equipment’s operation?

  Yes

  No

• Traffic control and signage checked regularly?

  Yes

  No

  N/A

• Vehicle/plant checks done and vehicle/plant logbooks filled out as required?

  Yes

  No

  N/A

Name of site inducted attendee

• City of Gold Coast employee #/company name

• White/blue card #

• Signature of site inducted attendee

  Sign

• Contractor SWMS sighted?

  Yes

  No

  N/A

Name of Traffic Controller

• Name

• Traffic control licence #

• White/blue card #

Acknowledgement

• I have read and understood all relevant documentation which is related to the task at hand.

  Yes

  No

• Signature of person/s completing pre-start

  Sign

Additional workers sign on

• Add signature

  Sign

• Add signature

  Sign

• Add signature

  Sign

• Add signature

  Sign

• Add signature

  Sign

• Add signature

  Sign

Additional information

• Include additional information required for this job, such as issues encountered from either a task or WHS perspective. Include photos for future reference/evidence.