Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Location

Risk Assessment

  • To complete this permit to work you must:

  • 1. Identify the hazard present on the job and the action to be taken to remove or reduce the risk of injury

  • 2. Use the site specific hazards listed below

  • Note: Take into account any person who may be affected by hazards associated with the work

Work Details

  • Company name and staff

  • Contact name and number

  • Description of work

  • Photos of work site

Persons at risk

  • Who could be harmed by the work - please select all applicable people

Hazard Identification

  • 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

  • Slips, trips or falls

  • Action taken to reduce the risk

  • Residual risk remaining after action

  • Falls from height or roof work

  • You must obtain an additional permit for this type of work

  • Action taken to reduce the risk

  • Residual risk remaining after action

  • Falling objects

  • Action taken to reduce the risk

  • Residual risk remaining after action

  • Chemicals

  • Action taken to reduce the risk

  • Residual risk remaining after action

  • Heat/fire/Hot Work

  • An additional permit is required for this work

  • Action taken to reduce the risk

  • Risidual risk remaining after action

  • Asphyxiation

  • Action taken to reduce the risk

  • Residual risk remaining after action

  • Asbestos

  • Please refer to the Asbestos Management Plan before proceedign with any work

  • Action taken to reduce the risk

  • Residual risk remaining after action

  • Overturn/Collapse

  • Action taken to reduce the risk

  • Residual risk remaining after action

  • Manual Handling

  • Action taken to reduce the risk

  • Residual risk remaining after action

  • Mobile Equipment

  • Action taken to reduce the risk

  • Residual risk remaining after action

  • Confined Space

  • An additional permit is required for this type of work

  • Action taken to reduce the risk

  • Residual risk remaining after action

  • Dust and/or fumes

  • Action taken to reduce the risk

  • Residual risk remaining after action

  • Noise

  • Action taken to reduce the risk

  • Residual risk remaining after action

  • Electricity

  • Action taken to reduce the risk

  • Residual risk remaining after action

  • Contamination

  • Action taken to reduce the risk

  • Residual risk after action

  • Poor Lighting

  • Action taken to reduce the risk

  • Residual risk remaining after action

  • Temperature

  • Action taken to reduce the risk

  • Residual risk remaining after action

  • Adverse weather

  • Action taken to reduce the risk

  • Residual risk remaining after action

  • Uncertified equipment

  • Action taken to reduce the risk

  • Residual risk remaining after action

  • Pressure/Gases

  • An additional permit is required for this type of work

  • Action taken to reduce the risk

  • Residual risk remaining after action

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Additional Notes

  • Enter ny additional information

This is a record of the Site Specific Risk Assessment conducted for teh above work

  • Name

  • Signature

  • Date

Continuation, if this assessment continues for more than one day and the conditions have not changed, Sign and Date

  • Signature

  • Date

  • Signature

  • Date

  • Signature

  • Date

If conditions change, then a NEW assessment MUST be completed before work commences

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.