Time Take 5 Checklist completed

Is this task part of a Job?


Is there a work instruction for this task?

Has this task been identified in my JHA?

Does this task present any immediate hazards to others nearby?

Am I trained to do this task?


Have I communicated with other work groups any hazards that may affect them or me?

Are the controls from my JHA in place?

What hazards are around me "here and now"?




Do I have all the permits required for this task?

Do I have the correct tools & equipment?

Is the equipment isolated and I applied my red locks (if required)

Operator Signature
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.