Title Page

  • Work Area

  • Contractor

  • Conducted on

  • Prepared by

  • Location

Part A

General Area - PPE, Housekeeping, HAZMAT, Fire Extinguishers

  • PPE Boxes stocked? Storage areas for RPE clean and dust proof?

  • Add media

  • PPE Signage in Place?

  • Add media

  • Correct PPE for task and correctly worn?

  • Add media

  • Housekeeping is good and free of trip hazards?

  • Add media

  • Recycling in correct bins? All bins labelled correctly?

  • Add media

  • Waste Stored Correctly?

  • Add media

  • Hydrocarbon Bunds in place?

  • Add media

  • HAZMATs stored in cabinets when not in use?

  • Add media

  • Chemicals all stored correctly and labelled?

  • Add media

  • SDS are nearby and available?

  • Add media

  • Fire Cabinets - self closing and lock attached?

  • Add media

  • Fire Extinguishers are the correct type and within date? And appropriately signed?

  • Add media

Part B

Emergency Facilities & First Aid

  • Emergency eye wash and shower signs fitted and visible?

  • Add media

  • Are trauma kits available in work areas and LVs?

  • Add media

  • All exits and access/egress to escape are kept clear and free of obstruction?

  • Add media

  • Emergency Muster point clearly marked and known?

  • Add media

  • Do operators have means of positive communication? Is the Emergency channel known?

Part C

Electrical

  • All portable electrical items tagged with current electrical tag?<br>Dec-Feb = Red<br>Mar-May = Green<br>Jun-Aug = Blue<br>Sep-Nov = Yellow

  • Add media

  • Leads, Plugs and sockets in good order?

  • Add media

  • Leads off the ground and not exposed to water?

  • Add media

  • ELCB/RCD used for portable tools?

  • Add media

Part D

Hot Work

  • Hazardous Areas identified correctly?

  • Add media

  • Flashback arrestors on cylinders and hand pieces?

  • Add media

  • Fire extinguishers available for all HW?

  • Add media

  • Acetylene Bottles correctly stored/secured with frame lift point tagged/certified?

  • Add media

  • Earth leads on Welders in good condition?

  • Add media

  • All tools and equipment in good condition (no hard face, mushroom heads, splitting on drifts, loose or split heads or handles)?

  • Add media

  • All 9" grinders have been removed?

Part E & F

Confined Spaces

  • Signage - Do all entrances and hatches to confine spaces have appropriate signage? Is hot work in areas not currently defined as a CS now meet the definition?

  • Add media

Conveyors (walk around plant)

  • Rollers - do rollers have idler protection guards? Have guards been returned to plant appropriately?

  • Add media

  • Warning Sirens - is the siren sounded to warn persons that the conveyor is starting?

  • Add media

  • Signage - Are the correct signs in place ("restricted area" "danger conveyor starts automatically")?

  • Add media

  • Signage - Are the signs clean and readable?

  • Add media

  • Product - Is there any hang-up evident or visible?

  • Add media

Part G

Scaffolding

  • Scaffolds (tagged and less than 30 days old?)

  • Add media

  • Are yellow self-closing gates present?

  • Add media

  • Any dropped object hazards that could fall and cause injury?

  • Add media

  • Excess scaffold equipment not removed from the area?

  • Add media

Part H

Working at Heights & Dropped Objects

  • Safety harness in good condition and correctly tagged?<br>Dec-Feb = Red<br>Mar-May = Green<br>Jun-Aug = Blue<br>Sep-Nov = Yellow

  • Add media

  • Tool lanyards being used whilst working at height?

  • Add media

  • Lanyard and Inertia reels in good condition and tagged?

  • Add media

  • Dropped Objects - Are barriers in place and controls being used?

  • Add media

  • Are materials stacked next to handrails creating the potential for dropped objects?

  • Add media

  • Where floor panels/grid mesh have been removed, does the permit detail this? Are there barricades in place to manage falls? Has it been put back in place afterwards?

  • Add media

Part I

Guards and Handrails

  • Are there adequate handrails, guards or fences provided on all steps, stairs, elevated walkways, and platforms where there is a risk of falling?

  • Add media

  • Are handrails in good condition, minimum height of 1200mm, with a mid rail and toe board?

  • Add media

  • Ladders - Are ladders on elevated structural ladders enclosed?

  • Add media

  • Are all moving parts on machinery that could cause a risk of injury screened or guarded to prevent contact?

  • Add media

Part J & K

Crane Operations and Equipment

  • Are Cranes and working zones correctly barricaded on the ground & the levels?

  • Is the rigging gear in good condition and appropriately tagged?

Exclusion Zones

  • Is exclusive control used to strictly control the group's work area?

  • Add media

  • Exclusive control tape is not connected to any other tape?

  • Add media

  • Is the single point of entry clearly defined?

  • Add media

  • Is the JHA located at point of entry/exit and all relevant personnel signed on?

  • Add media

  • Are information tags attached?

  • Add media

  • Do the information tags contain the appropriate information and are legible?

  • Add media

  • Is Danger tape being used correctly as NO GO areas that identify an area that contains a serious, major or catastrophic hazard?

  • Add media

  • Is the caution tape used correctly to identify minor or medium level hazards?

  • Add media

Part L

Isolations

Group Isolations

  • Has everyone working the task placed their Red Lock on the Work Permit Board?

  • Do all red locks have a Personal Danger tag attached?

  • Personal Danger tags correctly filled out and legible?

  • Have all in the work group signed the Permit Signature sheet?

  • Is the isolation statement authorised and signed?

  • Is there an associated Work Permit?

Simple Isolations

  • Is each isolation point locked with a black lock and tag?

  • Hasps are not daisy-chained?

  • Have the work group placed their personal danger lock and tag on the hasp of the isolation point?

  • Is the personal danger tag correctly filled in and legible?

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.