PFM Take 5 - Cyclical Maintenance

• Conducted on

  Date

• HWA Works Order # (if applicable):

• Technicians Full Name:

• Location
  Address

Take 5 Safety Assessment Questionnaire

• Am I fit for work? <br>If No, do not proceed, speak with Supervisor, works may need to be reassigned.

  Yes

  No

• Could Asbestos be present or disturbed by completing the job / task? <br>If YES, speak with Supervisor, or if proceeding complete & provide SWMS for Asbestos Management (where applicable)

  Yes

  No

• Do I understand the task / job and equipment to be used ? If NO, seeking clarification before works commence!

  Yes

  No

• Could I slip or trip on anything? If YES, document how are you mitigating this risk?

  Yes

  No

• Am I competent / authorized for this task ? <br>If No, do not commence works and contact your or a PFM Supervisor!

  Yes

  No

• Could I fall from height? - <br>If YES, complete & provide SWMS for Working @ Heights before works commence

  Yes

  No

• Are all tools and equipment fit for purpose? <br>If No, source compliant tools and equipment before works commence and document that this has occurred.

  Yes

  No

• Will my task put anyone else at a safety risk ? <br>If Yes, document how you are mitigating this risk!

  Yes

  No

• Is the work area adequate for the task? <br>If No, document how you are going to mitigate this risk!

  Yes

  No

• Could I be caught between anything? <br>If Yes, document how you are going to mitigate this risk.

  Yes

  No

• Have I identified all STORED energies ? (Electricity, Hydraulic, Pneumatic)

  Yes

  No

• Could I strain or over exert myself? <br>If Yes, document how you will mitigate this risk!

  Yes

  No

• Is there a SOP / SWP / SWMS for the task ?<br>If Yes, complete documents ahead of works commencing and upload a copy into Loc8.

  Yes

  No

• Do I need to enter "confined space" ? <br>If YES, complete & provide SWMS for Working in confined spaces!

  Yes

  No

• Am I protected from the effects of weather and climate? <br>If NO, document how you are mitigating the risks associated with this!

  Yes

  No

• Will the activities of others in the area affect me ? <br>If Yes, document the issue and how you will mitigate the risk!

  Yes

  No

• Have all hazards & controls been identified within this Take 5? <br>If No, conduct a formal risk assessment for the job/task.

  Yes

  No

• Additional Hazards identified and/or other controls or comments to note:

I have completed the Take 5 Safety Assessment whilst on site and agree to implement all controls required to ensure a safe working environment.

• Signed

  Sign