Title Page

  • Site conducted

  • Prepared by

  • Other persons working on task

  • Date

  • Description of work

  • Location

Take 5 Checklist

  • Am i fit for the job?

  • Please contact your supervisor before conducting any work.

  • Do I have approval to perform this task

  • Please contact your supervisor before conducting any work.

  • Do I 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.

  • Have all energy sources been identified, isolated, locked out and tagged out??

  • All energy sources must be isolated when being worked on. If this is not possible, discuss with your supervisor/manager.

  • Are machine guards in place?

  • If working without guards on a live machine, a Live Work Permit is required to be filled out daily.

  • Have I inspected my work area for hazards?

  • Note any hazards you can identify.

  • Do I need to communicate to my surrounding workmates the risks associated with this task?

  • Communicate with people working in your vicinity, explain what your task is, hazards involved and actions they need to take.

  • Is there something that can fall on me or others?

  • Minimise/isolate/eliminate hazards. Note down any hazards that remain for your task, provide methods of hazard management. Provide pictures if possible.

  • Can I fall from height, slip or trip on anything?

  • Minimise/isolate/eliminate hazards. Note down any hazards that remain for your task, provide methods of hazard management. Provide pictures if possible.

  • Is elevated work platform (man cage) being used?

  • Show equipment is in date. Ensure occupant and operators are competent as required.

  • Can I be crushed or struck by any plant or machinery?

  • Minimise/isolate/eliminate hazards. Note down any hazards that remain for your task, provide methods of hazard management. Provide pictures if possible.

  • Do I need to read the Safety Data Sheets?

  • Minimise/isolate/eliminate hazards. Note down any hazards that remain for your task, provide methods of hazard management. Provide pictures if possible.

  • Are there environmental factors that could be hazardous?

  • Minimise/isolate/eliminate hazards. Note down any hazards that remain for your task, provide methods of hazard management. Provide pictures if possible.

  • Is there a chance that I can spill/pollute/damage/disturb the environment?

  • Minimise/isolate/eliminate hazards. Note down any hazards that remain for your task, provide methods of hazard management. Provide pictures if possible.

  • Has anything changed since the last time I did this task?

Are Permits Required?

  • Confined Space Entry Permit?

  • Enter Permit# Conform to permit requirements and complete work according to safe work practice.

  • Hot Work Permit?

  • Enter Permit# Conform to permit requirements and complete work according to safe work practice.

  • Working at heights Permit? (Scaffolding tagged)

  • Enter Permit# Conform to permit requirements and complete work according to safe work practice.

  • Notification of hazardous Works?

  • Enter Permit# Conform to permit requirements and complete work according to safe work practice.

  • Traffic Management plan?

  • Enter Permit/Plan# Conform to permit requirements and complete work according to safe work practice.

  • Lock Out Tag/Isolation Permit?

  • Enter Permit# Conform to permit requirements and complete work according to safe work practice.

Risk Assessment Matrix

  • Use this to determine score

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  • Referring to the risk matrix what is the risk score before hazard control measures?

  • What control measures are put in place?

  • Referring to the risk matrix what is the risk score AFTER hazard control measures?

  • Do not proceed with this task, more hazard control is required.

  • Supervisor Signature Required.

  • Proceed with caution.

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.