Orange Kiwi - Take 5 Safety Checklist and Risk Assessment

• Conducted on

  Date

• Prepared by

• Location
  Address

• Have you received induction training?

  Yes

  No

  N/A

• Do you know the company’s health & safety rules?

  Yes

  No

  N/A

• Are you familiar with how to report hazards & incidents?

  Yes

  No

  N/A

• Are there emergency facilities and an evacuation procedure/route for the site?

  Yes

  No

  N/A

• Do you have access to appropriate emergency and first aid equipment?

  Yes

  No

  N/A

• Have you asked the person in charge about all relevant hazards?

  Yes

  No

  N/A

• Do you have the correct procedures and equipment to do the work safely?

  Yes

  No

  N/A

• Is there appropriate separation of vehicles and people during the proposed work?

  Yes

  No

  N/A

• Is all required electrical/mechanical equipment in a safe condition?

  Yes

  No

  N/A

• Are hazardous/dangerous substances used and stored according to their safety data sheets?

  Yes

  No

  N/A

• Have you consulted with workers about the task and the safe way to do it?

  Yes

  No

  N/A

• Do you have all necessary PPE?

  Yes

  No

  N/A

• Have you got a safe way of getting in and out of your work area?

  Yes

  No

  N/A

• Have any manual handling risks been identified and accessed?

  Yes

  No

  N/A

General

• Task Description

Before Task Commences

• Do I clearly understand what is required?

  Yes

  No

  N/A

• Am I trained to do the work and familiar with the equipment/task?

  Yes

  No

  N/A

• Are the tools and equipment in a safe condition?

  Yes

  No

  N/A

• Do I have approved documentation for the task?

  Yes

  No

  N/A

• Am I safe from other activities/tasks in the area?

  Yes

  No

  N/A

• Have I informed others who may be aff ected by my work?

  Yes

  No

  N/A

• Do I have the correct PPE for the Task?

  Yes

  No

  N/A

Hazards

• Have I identified any hazards associated with the task?

  Yes

  No

  N/A

• Description of Hazards

• Description of Controls

Risk Assessment

• Have all hazard controls been implemented?

  Yes

  No

  N/A

• Have all potential problems been discussed and understood by all?

  Yes

  No

  N/A

• Can the Task proceed safely?

  Yes

  No

  N/A

• Sign off

  Sign