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

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