Title Page
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Document No.
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Conducted on
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Conducted by
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Names of other people involved
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Location
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Description of task
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Location of task
Identify Hazards
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Can i strain or over exert myself?
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Please enter control measure
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Can i fall from a height?
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Please enter control measure
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Can i be trapped/caught by plant?
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Please enter control measure
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Is there a risk from chemicals?
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Please enter control measure
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Can i recieve burns (hot or cold)?
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Please enter control measure
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Is there a risk of fire?
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Please enter control measure
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Can i slip, trip or fall?
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Please enter control measure
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Does stored energy need isolating?
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Please enter control measure
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Are there sharp edges and rotating parts?
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Please enter control measure
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Am i working with radiation?
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Please enter control measure
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Does my work impact others?
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Please enter control measure
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Identify Hazards
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Am i fit for the job?
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Please enter control measure
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Am i trained and authorised to perform the task?
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Please enter control measure
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Am i aware of site emergency procedures?
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Please enter control measure
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Site emergency contact details
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Do i require PPE?
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Safety glasses
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Safety boots
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Long sleeves and pants
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Goggles
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Face shield
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Splash apron
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Nitrile gloves
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Double layer gloves
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Leather gloves
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Chemical suit
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Chemical boots
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Cutting gloves
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Hard hat
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Sun protection
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Dust suit
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Hearing protection
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Respirator
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Hearing protection
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Other PPE
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Do i require a work permit (hot work, confined space, etc.)?
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Please enter control measure
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Do i need to restrict access to the work area?
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Please enter control measure
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Do i have safe access and egress?
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Please enter control measure
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Do i need an SDS?
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Please enter control measure
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Any other concerns?
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Please enter control measure
