Title Page

  • Site conducted

  • Prepared by

  • Other persons working on task

  • Date

  • Description of work

  • Location
  • Are you fit to work today?

  • Do you have approval to perform your task?

  • Do you have the correct tools, equipment and PPE? Are they in good condition and within test dates?

  • 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.

  • Are there any new hazards on site today?

  • State the hazard and your method of control.

  • Is there any other new hazards on site today?

  • State the hazard and your method of control.

  • Are permits still open for work if required?

  • If permit was closed, open a new permit for the work to be conducted and upload a photo via JSA/ permit record template.

Sign Off

  • 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

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.