MONADELPHOUS - INTERACTION

• Document No.

• Task(s) Performed

• Client / Site

• Conducted on

  Date
• Location
  Address

• Personnel (Optional)

Positive Observations

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At Risk Actions / Conditions

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At Risk Items Rectified

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Opportunities for Improvement

• Observers Name:

  Sign

CHECKLIST - Tick if Any AT RISK

• People

  Select Line of Fire (eg. struck by/against Pinch Points (eg. caught in/on/between Position/Posture (eg. awkward, static) Movements (eg. repetitive) Falling (eg. fall from height, trip) Manual Handling (eg. push/pull, lift/lower) Hazardous Substance (eg. contact, inhalation) Temperature Extremes Contact with Electricty NIL

  • Line of Fire (eg. struck by/against
  • Pinch Points (eg. caught in/on/between
  • Position/Posture (eg. awkward, static)
  • Movements (eg. repetitive)
  • Falling (eg. fall from height, trip)
  • Manual Handling (eg. push/pull, lift/lower)
  • Hazardous Substance (eg. contact, inhalation)
  • Temperature Extremes
  • Contact with Electricty
  • NIL

• Job Set-Up

  Select Housekeeping Barricades (eg. exclusion/drop zones) PPE (eg. selection, condition, use) Dropped Objects (eg. lanyards) NIL

  • Housekeeping
  • Barricades (eg. exclusion/drop zones)
  • PPE (eg. selection, condition, use)
  • Dropped Objects (eg. lanyards)
  • NIL

• Job Planning

  Select JHA (eg. complete, adequate, followed) Take 5 (eg. complete, adequate, followed) Permits/Isolations (eg. complete, tested) Competency Verified (eg. PAR/VOC) NIL

  • JHA (eg. complete, adequate, followed)
  • Take 5 (eg. complete, adequate, followed)
  • Permits/Isolations (eg. complete, tested)
  • Competency Verified (eg. PAR/VOC)
  • NIL

• Tools / Equipment

  Select Selection (eg. right for the job) Condition (eg. safe, tested/tagged) Use (eg. used correctly) NIL

  • Selection (eg. right for the job)
  • Condition (eg. safe, tested/tagged)
  • Use (eg. used correctly)
  • NIL

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