Nautical Roofing COMPETENCY DECLARATION

• Document No.

• Competency Declaration for (Company Name / Individual):

• Worker/Operators Name

• Site Address
  Address

• Conducted on

  Date

• Employer Representative Name (Supervisor/Manager)

SECTION 1 - to be completed for each worker

• Name of worker/plant operator

• Address

• Phone number

• Any allergies? (If "yes" please list)

  Yes

  No

• Any pre-existing medical conditions?

  Select None Allergies Arthritis Asthma Back Pain Depression Diabetes Dyslexia Ear Problems Eye Problems Hearing Loss Hernias Heart Problems Migraines Neck Pain Skin Cancers Vertigo Other

  • None
  • Allergies
  • Arthritis
  • Asthma
  • Back Pain
  • Depression
  • Diabetes
  • Dyslexia
  • Ear Problems
  • Eye Problems
  • Hearing Loss
  • Hernias
  • Heart Problems
  • Migraines
  • Neck Pain
  • Skin Cancers
  • Vertigo
  • Other

• If "other" please specify:

• Age of worker

  Under 21

  21 or over

• If under 21, has the Young & Inexperienced Workers Induction (Form 13 in Safety Folder) been completed successfully?

  Yes

  No

  N/A

• Experience of worker in the industry

  Less than 1 year

  1 year or more

• If less than 1 year, has the Young & Inexperienced Workers Induction (Form 13 in Safety Folder) been completed successfully?

  Yes

  No

  N/A

• Emergency Contact

• Emergency Contact Number

• Attach photo of Blue/Whitecard and Working at Heights

  Media

• The following statement may be used for confirmation of competency of the worker as declared by the employer, certifying that they have assessed and deemed the worker competent and capable of undertaking assigned work including occupational health and safety and environmental activities and tasks to be conducted on all Nautical Roofing projects, and/or to deem them competent to operate powered mobile plant on Nautical Roofing projects.

• I have assessed and deemed this worker competent to undertake the tasks and activities they will be assigned and we, their employer, confirm they are competent to carry out occupational health, safety and environmental activities and tasks assigned to them and have provided information, training and instruction, including relevant documentation, so they may complete the required work assigned to them and will ensure they are supervised and monitored during the conduct of the work to ensure compliance with all agreed systems of work.

• Employer Representative Name (Manager/Supervisor):

  Sign

• I agree that all the information above is true and accurate at the time of signing this document.

• Workers Name

  Sign

SECTION 2 - to be completed for SCISSOR LIFTS operators

• Does the operator possess a YELLOW EWP CARD for this item? (Not essential, but would strongly recommend it)

  Yes

  No

  N/A

• Attach a clear photo of the Certificate/Card and number

  Media

• Is the operator competent and able to perform all pre-start operational checks for the item including all necessary occupational health, safety and environmental control or procedures as relevant? (Ask operator to conduct pre-start in front of you)

  Yes

  No

  N/A

• Is the operator competent and able to identify and operate all functional controls on the item? (Ask operator to demonstrate verbally)

  Yes

  No

  N/A

• Has the operator been observed by the assessor (you) as operating the item of plant or equipment safely as per manufacturer's operations and other manuals and procedures? (Ensure Manual is with item of plant at all times)

  Yes

  No

  N/A

• Is the operator aware of environmental impacts that the plant may pose to the environment?

  Yes

  No

  N/A

• Is the operator competent in using spill kits and the refuelling process?

  Yes

  No

  N/A

• Is the operator aware of the reporting process for environmental incidents?

  Yes

  No

  N/A

• Do you authorise the operator to operate this item of plant or equipment?

  Yes

  No

  N/A

• NOTE: The person who performs the above checks must be at least a Supervisor/Manager for the business and competent in and familiar with the operation of the item before they are allowed to complete this Competency Declaration.

• Assessor Name (Supervisor/Manager)

  Sign

SECTION 3 - to be completed for OVER 11m BOOM operators

• Is a certificate of competency required to operate this item of plant or equipment?

  Yes

  No

  N/A

• Does the operator possess a current certificate of competency for this item? (WP High Risk Licence with photograph)

  Yes

  No

  N/A

• Attach a clear photo of the Certificate/card and number

  Media

• Is the operator fully qualified and not under a training agreement? (If NO, provide name and number of RTO, photo of agreement, and name of competent person to directly supervise the operator)

  Yes

  No

  N/A

• Is the operator competent and able to perform all pre-start operational checks for the item including all necessary occupational health, safety and environmental control or procedures as relevant? (Ask operator to conduct pre-start in front of you)

  Yes

  No

  N/A

• Is the operator competent and able to identify and operate all functional controls on the item? (Ask operator to demonstrate verbally)

  Yes

  No

  N/A

• Has the operator been observed by the assessor (you) as operating the item of plant or equipment safely as per manufacturer's operations and other manuals and procedures? (Ensure Manual is with item of plant at all times)

  Yes

  No

  N/A

• Is the operator aware of environmental impacts that the plant may pose to the environment?

  Yes

  No

  N/A

• Is the operator competent in using spill kits and the refuelling process?

  Yes

  No

  N/A

• Is the operator aware of the reporting process for environmental incidents?

  Yes

  No

  N/A

• Do you authorise the operator to operate this item of plant or equipment?

  Yes

  No

  N/A

• NOTE: The person who performs the above checks must be at least a Supervisor/Manager for the business and competent in and familiar with the operation of the item before they are allowed to complete this Competency Declaration.

• Assessor Name (Supervisor/Manager)

  Sign