Pre-Task Planning Questionnaire

• Document No.

• Contract Number

• Job Number

• Description of Work

• Conducted on

  Date

• Prepared by

• Team Members

• Location
  Address

Traffic Management Plan

• What is your Traffic Management Qualification?

  STMS

  TC

  None

• Enter your STMS/TC Number

• Can you park in a safe area?

  Yes

  No

  N/A

• Is there good visibility in both directions?

  Yes

  No

  N/A

• Will you be working in a live lane?

  Yes

  No

  N/A

• Do you require a spotter?

  Yes

  No

  N/A

• Is work within an established site? (If yes, continue to safety checklist)

  Yes

  No

  N/A

• Is work within the Rail or State Highway Corridor? (If yes, you will require permission)

  Yes

  No

  N/A

• Do you require a TMP?

  Yes

  No

  N/A

• Can the work be completed under an ESG Generic TMP?

  Yes

  No

  N/A

Safety Checklist

• Have you walked over the site to IDENTIFY SAFETY CONCERNS and familiarise yourself with the work area?

  Yes

  No

  N/A

• Is the AREA SAFE for working?

  Yes

  No

  N/A

• Have you CO-ORDINATED YOUR WORK with others in the area?

  Yes

  No

  N/A

• Are all TOOLS AND EQUIPMENT safe for use?

  Yes

  No

  N/A

• Have you completed all TRAINING necessary to complete the task safely?

  Yes

  No

  N/A

• Are there large TRAFFIC VOLUMES in the area?

  Yes

  No

  N/A

• Has SUFFICIENT PERSONNEL been assigned to complete this task safely?

  Yes

  No

  N/A

Personal Protective Equipment - PPE

• Check all PPE necessary to complete this task

  Select Reflective Clothing Footwear Eye Protection Hard Hat Sunscreen Wet Weather Gear Gloves Long Sleeves or Pants Other

  • Reflective Clothing
  • Footwear
  • Eye Protection
  • Hard Hat
  • Sunscreen
  • Wet Weather Gear
  • Gloves
  • Long Sleeves or Pants
  • Other

• If other is selected, specify here:

• Signature

  Sign