Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
Risk Assessment
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To complete this permit to work you must:
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1. Identify the hazard present on the job and the action to be taken to remove or reduce the risk of injury
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2. Use the site specific hazards listed below
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Note: Take into account any person who may be affected by hazards associated with the work
Work Details
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Company name and staff
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Contact name and number
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Description of work
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Photos of work site
Persons at risk
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Who could be harmed by the work - please select all applicable people
- Contractor
- Maintenance Staff Member
- Factory Staff Member
- Onlooker
Hazard Identification
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A action must be taken if a hazard is present. If the residual risk is still high after the action is completed you must not proceed with the work
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Slips, trips or falls
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Action taken to reduce the risk
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Residual risk remaining after action
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Falls from height or roof work
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You must obtain an additional permit for this type of work
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Action taken to reduce the risk
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Residual risk remaining after action
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Falling objects
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Action taken to reduce the risk
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Residual risk remaining after action
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Chemicals
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Action taken to reduce the risk
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Residual risk remaining after action
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Heat/fire/Hot Work
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An additional permit is required for this work
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Action taken to reduce the risk
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Risidual risk remaining after action
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Asphyxiation
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Action taken to reduce the risk
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Residual risk remaining after action
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Asbestos
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Please refer to the Asbestos Management Plan before proceedign with any work
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Action taken to reduce the risk
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Residual risk remaining after action
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Overturn/Collapse
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Action taken to reduce the risk
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Residual risk remaining after action
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Manual Handling
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Action taken to reduce the risk
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Residual risk remaining after action
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Mobile Equipment
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Action taken to reduce the risk
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Residual risk remaining after action
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Confined Space
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An additional permit is required for this type of work
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Action taken to reduce the risk
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Residual risk remaining after action
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Dust and/or fumes
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Action taken to reduce the risk
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Residual risk remaining after action
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Noise
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Action taken to reduce the risk
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Residual risk remaining after action
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Electricity
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Action taken to reduce the risk
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Residual risk remaining after action
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Contamination
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Action taken to reduce the risk
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Residual risk after action
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Poor Lighting
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Action taken to reduce the risk
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Residual risk remaining after action
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Temperature
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Action taken to reduce the risk
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Residual risk remaining after action
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Adverse weather
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Action taken to reduce the risk
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Residual risk remaining after action
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Uncertified equipment
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Action taken to reduce the risk
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Residual risk remaining after action
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Pressure/Gases
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An additional permit is required for this type of work
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Action taken to reduce the risk
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Residual risk remaining after action
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Additional Notes
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Enter ny additional information
This is a record of the Site Specific Risk Assessment conducted for teh above work
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Name
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Signature
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Date
Continuation, if this assessment continues for more than one day and the conditions have not changed, Sign and Date
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Signature
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Date
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Signature
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Date
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Signature
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Date
