• Work Order No.

  • Site Name

  • Conducted on

  • Prepared by

  • Personnel


  • Rate condition of access roads.

  • Rate condition of parking areas.

  • Rate condition of stairs, paths and railings.

  • Rate condition of fences.

  • Rate condition of gates.

  • Rate condition of locks.

  • Rate condition of park furniture (tables/chairs/benches).

  • Rate condition of waste facilities (bins, etc).

  • Are bubblers and taps working?

  • Do electric BBQ's operate correctly?

  • Do electric BBQ's shut off correctly?

  • Does boiling water unit operate correctly?

  • Is information signage visible and secure?

  • Is safety signage visible and secure?

  • Are effluent systems operating correctly?

  • Are septic tank lids secure?

  • Does level indicator show volume above 70%?

  • If level is above 70%, arrange for pump out service?

Level of service

  • Please rate the general appearance of the site.


  • Has grass maintenance been undertaken to specification?

  • Has litter and debris been removed to service specification?

  • Are gardens maintained to specification?

Cleaning standards

  • Is park furniture serviced to specification?

  • Are areas outside of fence lines free of litter and rubbish?

  • Are garbage bins serviced to specifications?

  • Are toilets serviced to contract specification?

  • Do toilets have adequate toilet paper?

  • Are shelter sheds clean and tidy?

  • Are walls and equipment free of graffiti?


  • Are shelter sheds, chairs, and tables safe?

  • Are traffic barriers safe and secure?

  • Is the area free of dangerous overhanging trees?

  • Please rate the overall safety of the site.

WHS Hazards

  • We're any WHS hazards identified?

  • Hazard
  • Hazard identified by:

  • Where is the hazard located?

  • Describe the hazard.

  • Has anything been done about the hazard?

  • What corrective action was taken?

  • Signature

  • Complete hazard export form 0901.

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.