Information
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Task
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Customer / Site
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Location
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Actioned by
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Date
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Document No.
Part 1 - Stop For A Moment
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Before You Start
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Is the task clearly defined and do you have the right documentation and instruction sets to carry out the job?
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Have you had sufficient training and, been approved as a competent person to perform this task?
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Do you have the required permits to work, power isolation, emergency plans and temporary warning signs in hand?
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Do you have appropriate Personal Protective Equipment for the job and, have you been trained in its use?
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If your task could result in accidental chemical or oil spillage, do you have access to a spill control kit?
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Are your hand tools, power tools and extension leads in good condition and tested where applicable (e.g. PAT tested)?
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Has your measuring & test equipment been registered and calibrated (e.g. calibration stickers/labels current)?
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Have scaffolds, ladders and lifting equipment been inspected/tested (e.g. test stickers/labels are current)?
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Have all security issues been addressed (e.g. workplace clearance; your personal security and of your equipment)?
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If you have answered 'NO' to any of the above, take the required action or report it to your line manager for advice - If in doubt always ask!
Part 2 - Think
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What Are The Hazards?
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Slips, trips or falls on the same level
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Falls from height
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Falling / flying objects
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Chemicals / harmful substances (e.g. refrigerant gases)
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Heat / fire / explosion
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Asphyxiation / drowning
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Risk to plant
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Contact with stationary object
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Object overturning / collapsing
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Manual handling
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Stored energy
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Vehicles
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Risk to you from the work of others
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Risk to the environment (e.g. spillages & releases)
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Entry into a confined space
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Dust / fumes
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Asbestos
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Noise
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Vibration
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Electricity / Gas
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Radiation (ironising and non-ironising)
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Poor lighting
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Temperature & Pressure (high/low)
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Adverse Weather (e.g. high winds)
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Pinch / trapping points
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Risk to others from your work
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Management of waste materials
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Spilled body fluids and human waste
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Sharps (e.g. needles and blades)
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Sewage and sanitary waste
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Sources of infection (e.g. Leptospirosis & Legionella)
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Falls from height
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Automatic machinery start up
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Lone working
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Others (specify)
Part 3 - Act
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Additional Safety Assessment
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Hazards (If selected previously)
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Contol Measures / Precautions you have taken
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Remaining Risk*
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* If 'High' additional precautions are needed - no task should be undertaken with a 'High' risk remaining
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Task / Job closed out by - Name:
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Signature:
