North 4 HomeSafe 2017

• Engineer Details [**Payroll Number must be included**]

• Conducted On:

  Date

• Prepared By:

• Location
  Address

TM Risk Assessment

• Type of Risk/Hazard

  Select Parking Traffic Ground Third Party Weather

  • Parking
  • Traffic
  • Ground
  • Third Party
  • Weather

• Are Risks/Hazards Controllable?

  Select Yes No

  • Yes
  • No

• TM Risk Assessment Summary

Job Type

• Job Type

  Select Service Install Install Multi Screen MHO MHO Multi Screen

  • Service
  • Install
  • Install Multi Screen
  • MHO
  • MHO Multi Screen

• Job Number

I confirm that today's visit with the Engineer was unannounced.

• Yes

Engineer Working Safely on Arrival

• Yes

  No

Equipment Section

• Ladder Used

  Select Single Section Double Section Triple Section 12 Rung 14 Rung Combination Ladder A-Frame Combination Ladder (Single Section) Cat Ladder No Ladder Used

  • Single Section
  • Double Section
  • Triple Section
  • 12 Rung
  • 14 Rung
  • Combination Ladder A-Frame
  • Combination Ladder (Single Section)
  • Cat Ladder
  • No Ladder Used

• Ropes Used

  Select 5 Metre 10 Metre 15 Metre 5 Metre used as RSL

  • 5 Metre
  • 10 Metre
  • 15 Metre
  • 5 Metre used as RSL

• Specialist Engineer Set Up & Equipment Only

  Select Not Required DTH Only Extendable Cat Ladder Single DAT Ladder Set Up Double DAT Ladder Set Up Single Access Ladder Double Access Ladder Full DAT Equipment Set Up Full Roped Access Equipment Set Up

  • Not Required DTH Only
  • Extendable Cat Ladder
  • Single DAT Ladder Set Up
  • Double DAT Ladder Set Up
  • Single Access Ladder
  • Double Access Ladder
  • Full DAT Equipment Set Up
  • Full Roped Access Equipment Set Up

• RAMS Form Attached where required:

  Media

• S.S.O.W Equipment

  Select Microlite Ratchet Strap 10mm Eyebolt 20mm Eyebolt Double 10mm Eyebolt Other Means of Securing Ratchet Strap 10 Metre Strap Soft Slings Ladder Stopper (Gravel Bag) Chimney Strap Crawl Boards Laddermate

  • Microlite
  • Ratchet Strap
  • 10mm Eyebolt
  • 20mm Eyebolt
  • Double 10mm Eyebolt
  • Other Means of Securing Ratchet Strap
  • 10 Metre Strap
  • Soft Slings
  • Ladder Stopper (Gravel Bag)
  • Chimney Strap
  • Crawl Boards
  • Laddermate

• Fall Arrest Equipment

  Select DTH Harness SAT Harness Cows Tail Rope Grab Y-Hang

  • DTH Harness
  • SAT Harness
  • Cows Tail
  • Rope Grab
  • Y-Hang

P.P.E Equipment/Clothing

• P.P.E

  Select Safety Helmet Safety Boots Manual Handling Gloves Latex Gloves Lashing Kit Gloves Safety Goggles Safety Glasses Dust-Mask Over Ear Protection In Ear Protection

  • Safety Helmet
  • Safety Boots
  • Manual Handling Gloves
  • Latex Gloves
  • Lashing Kit Gloves
  • Safety Goggles
  • Safety Glasses
  • Dust-Mask
  • Over Ear Protection
  • In Ear Protection

Working at Height

• Working at height location

  Select Front/Back or Side Elevations Pitched Roof Access Pitched Roof with Chimney Access Dormer Roof Access/Chimney Access Flat Roof Working Loft Working

  • Front/Back or Side Elevations
  • Pitched Roof Access
  • Pitched Roof with Chimney Access
  • Dormer Roof Access/Chimney Access
  • Flat Roof Working
  • Loft Working

HomeSafe

• HomeSafe

  HomeSafe

  Unsafe

Visit Summaries

• Engineer Summary of today's visit: Stop-Start-Continue, What was good about today's visit? What could have been better about today's visit? After today's visit (if anything) what could you do differently?

• TM Summary of today's visit

• Media to support today's visit

  Media

Signatures

• TM Signature

  Sign

• Engineer Signature

  Sign