Information
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REGION
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Property Address
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Todays Date
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Task undertaken by
Safety - Take 5
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STOP
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Do you understand the task scope?
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Do you have a clear plan in mind?
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Do you understand the steps required to do the task?
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THINK
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Does the task specific procedure / JSA exist?
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Do you have the necessary permits?
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Are the tools and equipment in good order?
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Can the task impact others?
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Is your PPE appropriate for the task?
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Can the environment or surrounding environment change?
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Can hazards from associated work areas impact you?
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IF YOU ANSWERED NO TO THE ABOVE QUESTIONS AND ARE AT RISK FROM HAZARDS OR YOUR SAFETY IS IN ANY DANGER PLEASE CONTACT YOUR SUPERVISOR OR BRANCH MANAGER BEFORE CONTINUING
DETERMINE ACTION - Identify Actions
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Note: If any of the following HIGH RISK WORKS are involved with the job, works must carried out in accordance to a Safe Work Method Statement (SWMS) -
Working at Heights over 2m
Demolition
Asbestos
Alteration to a structure that requires the structure to be temporarily supported to prevent its collapse
Confined space
Excavation to a depth of more than 1.5 metres
Energised pressurised gas pipes (including distribution mains)
Chemical, fuel or refrigerant lines
Energised electrical installations and lines (both overhead or underground)
Work on or adjacent to roads that are in use
Movement of powered mobile plant -
My tasks do not involve HIGH RISK WORKS
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Select if hazards arise due to (select multiple):
- Elecrical
- Machinery
- Tools and Equipment
- Pressure
- Energised
- Noise
- Chemicals
- Stored Energy
- Environment
- Ground conditions
- Gravity
- Hot/Cold
- Dust
- Heights
- Open Holes
- Sharpness
- Flying objects
- Struck by
- Lifting
- Falls and Slips
- Ignition/Explosion
- OTHER
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What Is the Risk Rating?
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What could happen as a result of theses hazards?
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What will I do to remove or control the hazards in order to reduce the risk to as low as reasonably practicable?
Before & After Photos
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Before Photos
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After Photos
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Comments if any
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Sign off
