Queensland Urban Utilities- Sampling Run Site Assessment

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Work Environment

• Working Near Roadway/ Rail?

  Safe

  At Risk

  N/A

• Recommendations and Controls (Please note: if High/ Extreme risk is identified for this element, further risk assessment should be undertaken)

• Working near or adjacent to water?

  Safe

  At Risk

  N/A

• Recommendations and Controls (Please note: if High/ Extreme risk is identified for this element, further risk assessment should be undertaken)

• Working at heights?

  Safe

  At Risk

  N/A

• Recommendations and Controls (Please note: if High/ Extreme risk is identified for this element, further risk assessment should be undertaken)

• Uneven surface/ slopes?

  Safe

  At Risk

  N/A

• Recommendations and Controls (Please note: if High/ Extreme risk is identified for this element, further risk assessment should be undertaken)

• Slips, trips, falls?

  Safe

  At Risk

  N/A

• Recommendations and Controls (Please note: if High/ Extreme risk is identified for this element, further risk assessment should be undertaken)

• Flora/ fauna/ animals

  Safe

  At Risk

  N/A

• Recommendations and Controls (Please note: if High/ Extreme risk is identified for this element, further risk assessment should be undertaken)

Manual Tasks

• Height of access

  Safe

  At Risk

  N/A

• Recommendations and Controls (Please note: if High/ Extreme risk is identified for this element, further risk assessment should be undertaken)

• Reaching

  Safe

  At Risk

  N/A

• Recommendations and Controls (Please note: if High/ Extreme risk is identified for this element, further risk assessment should be undertaken)

• Extending

  Safe

  At Risk

  N/A

• Recommendations and Controls (Please note: if High/ Extreme risk is identified for this element, further risk assessment should be undertaken)

• Lifting

  Safe

  At Risk

  N/A

• Recommendations and Controls (Please note: if High/ Extreme risk is identified for this element, further risk assessment should be undertaken)

• Bending

  Safe

  At Risk

  N/A

• Recommendations and Controls (Please note: if High/ Extreme risk is identified for this element, further risk assessment should be undertaken)

• Twisting

  Safe

  At Risk

  N/A

• Recommendations and Controls (Please note: if High/ Extreme risk is identified for this element, further risk assessment should be undertaken)

• Awkward posture

  Yes

  No

  N/A

• Recommendations and Controls (Please note: if High/ Extreme risk is identified for this element, further risk assessment should be undertaken)

Effects of Inclement Weather

• Creek crossing- Wet?

  Safe

  At Risk

  N/A

• Recommendations and Controls (Please note: if High/ Extreme risk is identified for this element, further risk assessment should be undertaken)

• Creek crossing- dry?

  Safe

  At Risk

  N/A

• Recommendations and Controls (Please note: if High/ Extreme risk is identified for this element, further risk assessment should be undertaken)

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• Auditor Details

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• Auditee Signature

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