Title Page
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Site conducted
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Prepared by
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Other persons working on task
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Date
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Description of work
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Site contact
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Location
Take 5 Checklist
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Are you fit to work today?
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How are you unfit?
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Contact your supervisor/manager.
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Do I have approval to perform this task
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Who is able to give approval for this task?
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Do I have the correct tools, equipment and PPE? Are they in good condition and within test dates?
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Ensure you have all required equipment and that it is in good condition before undertaking your task. If this is not possible, contact your supervisor/manager.
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Have all energy sources been identified, isolated, locked out and tagged out??
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All energy sources must be isolated when being worked on. If this is not possible, discuss with your supervisor/manager.
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Are machine guards in place?
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If working without guards on a live machine, a Live Work Permit is required to be filled out daily.
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Have I inspected my work area for hazards?
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Note any hazards you can identify.
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Do I need to communicate to my surrounding workmates the risks associated with this task?
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Communicate with people working in your vicinity, explain what your task is, hazards involved and actions they need to take.
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Is there something that can fall on me or others?
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Minimise/isolate/eliminate hazards. Note down any hazards that remain for your task, provide methods of hazard management. Provide pictures if possible.
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Can I fall from height, slip or trip on anything?
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Minimise/isolate/eliminate hazards. Note down any hazards that remain for your task, provide methods of hazard management. Provide pictures if possible.
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Is elevated work platform (man cage) being used?
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Show equipment is in date. Ensure occupant and operators are competent as required.
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Can I be crushed or struck by any plant or machinery?
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Minimise/isolate/eliminate hazards. Note down any hazards that remain for your task, provide methods of hazard management. Provide pictures if possible.
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Do I need to read the Safety Data Sheets?
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Minimise/isolate/eliminate hazards. Note down any hazards that remain for your task, provide methods of hazard management. Provide pictures if possible.
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Are there environmental factors that could be hazardous?
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Minimise/isolate/eliminate hazards. Note down any hazards that remain for your task, provide methods of hazard management. Provide pictures if possible.
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Is there a chance that I can spill/pollute/damage/disturb the environment?
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Minimise/isolate/eliminate hazards. Note down any hazards that remain for your task, provide methods of hazard management. Provide pictures if possible.
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Has anything changed since the last time I did this task?
Are Permits Required?
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Confined Space Entry Permit?
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Enter Permit# Conform to permit requirements and complete work according to safe work practice.
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Hot Work Permit?
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Enter Permit# Conform to permit requirements and complete work according to safe work practice.
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Working at heights Permit? (Scaffolding tagged)
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Enter Permit# Conform to permit requirements and complete work according to safe work practice.
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Notification of hazardous Works?
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Enter Permit# Conform to permit requirements and complete work according to safe work practice.
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Traffic Management plan?
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Enter Permit/Plan# Conform to permit requirements and complete work according to safe work practice.
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Lock Out Tag/Isolation Permit?
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Enter Permit# Conform to permit requirements and complete work according to safe work practice.
Sign Off
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Confirm that the work is safe to undertake and that all practicable steps have been taken to reduce risks.
If there are outstanding hazards, contact your supervisor/manager. -
Employee Signature
