Information

OnSite Pre-survey document

  • Conducted on

  • Culvert Reference

  • Prepared by

Access

  • Address

  • GPS Location
  • Access Issues

  • Access Drawing

Works detail

  • Assessed priority

  • Nature of Works

Confined Space Classification

  • NC1<br>

  • NC2

  • NC3

  • NC4

Can works be conducted without the need to enter the Confined Space?

Confined Space Classification during work task/activities?

  • NC1

  • NC2

  • NC3

  • NC4

Self & Assisted Rescue at Confined Spaces

  • Self Rescue

  • Assisted Rescue

Specified Risks are: -

  • • Loss of consciousness arising from gas, fumes, vapours or the lack of oxygen

  • • Loss of consciousness arising from an increase in body temperature

  • • Serious injury arising from a fire or explosion

  • • Drowning from an increase in the level of liquid

  • • Asphyxiation from a free flowing solid or inability to reach a respirable atmosphere due to entrapment in a free flowing solid.

  • Approx length

  • Summary of findings

  • Silt sample required?

  • Number of men required for task

Inlet Structure

  • Photo of Inlet structure

  • Comments

  • Photo of Watercourse upstream from inlet

  • Comments

Culvert inlet

  • Height (mm)

  • Width (mm)

  • Water depth (mm)

  • Material

  • If other please detail

  • Approx silt depth at inlet (mm)

  • Additional notes

  • Overhead services

Access to Culvert

  • Type of land

  • If other please give details

  • Restrictions & contact numbers

Working area

  • Off road parking?

  • Restrictions / directions

  • Soft / uneven ground?

  • Restrictions / directions

  • Stock present?

  • Restrictions / directions

  • Traffic Management

  • Restrictions / directions

Bridges

  • Is there a bridge restricting access?

  • Location

  • Weight restriction

  • Width restriction (mm)

  • Height restriction. (mm)

Outlet structure

  • Photo of outlet structure

  • Comments

  • Photo of watercourse downstream from outlet

  • Comments

Culvert outlet

  • Height (mm)

  • Width (mm)

  • Water depth (mm)

  • Material

  • If other please detail

  • Approx silt depth at outlet (mm)

  • Additional notes

  • Overhead services

Access to culvert

  • Type of land

  • If other please give details

  • Restrictions & contact numbers

Working area

  • Off road parking?

  • Restrictions / directions

  • Soft / uneven ground?

  • Restrictions / directions

  • Live stock present?

  • Restrictions / directions

  • Traffic management

  • Restrictions / directions

Bridges

  • Is there a bridge restricting access?

  • Location

  • Weight restriction

  • Width restriction (mm)

  • Height restriction (mm)

Additional photographs

Additional photos

  • Additional photo 1

  • Note

  • Additional photo 2

  • Note

  • Additional photo 3

  • Note

  • Additional photo 4

  • Note

  • Additional photo 5

  • Note

  • Additional photo 6

  • Notes

Pollution & environmental control

Environmental & pollution control

  • Environmental or pollution Control Matters which might effect the risk Assessment .

  • Any other matters relevant to the risk Assessment ?

Sign off

Report preparation

  • Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.