Self Evaluation FY15

Information

Target - Self Evaluation FY15

Store Number
Store Name
Date Completed
Store Manager Signature

Instructions

Completing this checklist will assist in ensuring the site has completed significant safety actions over the past 12 months as per Targets Safety Program. This is a chance to review not onlt that actions have been done, but how well they have been done and what is the level of safety knowledge of Team Members and Managers.

What is a Self Evaluation?

The Self Evaluation is an opportunity for sites to assess how well they have been applying the SafetyCARE system to assist Target continually improve its Safety Performance.

Due to changes made to the Site Operational Plan, the Self Evaluation is a streamlined process that looks at how well sites have completed required safety actions.

Who completes a Self Evaluation?

The SafetyCARE procedures require the Site Manager to complete the Self Evaluation. As a minimum, Management completing the Self Evaluation must have completed SafetyCARE in the Workplace and Safety. Any untrained Team Member can be the second participant.

When do you complete a Self Evaluation?

The Self Evaluation is completed once a year when nominated in the Site Operational Plan.

How do you complete a Self Evaluation?

Complete the following checklist by reviewing the requested material and assessing if it meets the requirements to be compliant. To be compliant, each element must satisfy all of the criteria, just having an action completed does not necessarily mean this was enough for the item to have been completed as required.

The second part of the Self Evaluation is a Team Member and Team Manager questionnaire. The aim of the questionnaire is to test their knowledge of key parts of the safety program and if further training may be required. For any items where Team Member or Manager knowledge is at a Basic or No knowledge at all, include this as a topic in your store huddles to increase awareness.
To be fully completed 5 Team Members and 3 Managers are to be interviewed.
Photos can be added if required in the tool.

Any actions generated are to be added to the Site Operational Plan as a site specific action. For any further assistance please contact your Health and Safety Advisor.

What to do if you require assistance?

Contact your Regional Health & Safety Advisor for advice.

Self Evaluation Actions Section

Use the section below the Self Evaluation to
- Capture any comments relating to the question being reviewed.
- Outline any required actions to be transferred to the Site Operational Plan as a site specific action.

Filing

Upload a copy of the completed Self Evaluation to the Site Operational Plan under the Slef Evaluation action in September. Remember to include any actions as a site specific action to be tracked and closed off.

Each site can complete a Self Evaluation at any stage and upload to the Site Operational Plan.

Self evaluation questions

SELF EVALUATION

Question 1. InjuryCARE 1300 checklist InjuryCARE 1300 Launch Checklist was completed and program was launched successfully. (Refer SOP July FY15). To be compliant, all of the following must be satisfied; - Launch checklist actions have been completed and uploaded to the SOP.
If not compliant outline required action and transfer to Site Operational Plan as a Site Specific Action.
Question 2. Team Talks delivered Have all Team Talks over the past 12 months been delivered to ALL available Team Members and Management representatives within the month the Team Talks were released including; - InjuryCARE Team Talk(SOP July FY15). - Near Miss Team Talk(SOP May FY14). -EEO & Anti bullying Team Talk(SOP Feb FY14). To be compliant, all of the following must be satisfied; - Team Activity Sheets have been signed by all Team Members and Management and uploaded to the SOP. (Review Team Talk activity sheets uploaded for each outlined Team Talk delivered).
If not compliant outline required action and transfer to Site Operational Plan as a Site Specific Action.
Question 3. Traffic Management Plan Has site completed a Traffic Management Plan on approved template and contains required site information. (Refer SOP August FY15) To be compliant, all of the following must be satisfied; - Site Details are completed on the plan. - Site traffic hazards specific to the site are outlined and specific controls included. - Photo's are included of traffic area (note this is not mandatory but helps others understand the plan) - Site Risk Assessment section is completed. - Traffic Management Plan displayed in a prominent location in the receiving area.
If not compliant outline required action and transfer to Site Operational Plan as a Site Specific Action.
Question 4. Training Matrix Training Matrix Record is current and has; a.) Management Training History b.) Team Member Training History c.) Identified Training gaps have been scheduled into the site specific section of your Site Operational Plan (Refer SOP Jan FY14 and Sept FY15) *Note this task is also to be completed during September 2014. To be compliant, all of the following must be satisfied; - Training Matrix Record updated. - Site Specific Actions have been created to address any training gaps.
If not compliant outline required action and transfer to Site Operational Plan as a Site Specific Action.
Question 5. FY15 Planning Meeting FY15 Planning Meeting Actions have been completed so site is prepared to upcoming FY15; (Refer SOP July FY15) Note: If this action is non compliant, site is to contact your Health and Safety Advisor to organise coaching for FY 15 Planning. To be compliant, all of the following must be satisfied; - Copy of completed H&S Planning Meeting Minutes are uploaded to the SOP. - Copy of Scanned Feedback Form is uploaded to the SOP. - KPI update for FY14 summary results is completed and uploaded to the SOP. - Site has identified Risk Focus's for FY15 and has created Site Specific Actions in the SOP to capture what actions are required.
If not compliant outline required action and transfer to Site Operational Plan as a Site Specific Action.
Question 6. FY15 Safety Performance Targets Site has set FY15 Safety Performance Targets and displayed on the noticeboard. (Refer SOP August FY15 - Contained within the Health and Safety Committee Meeting Action) To be compliant, all of the following must be satisfied; - Copy of completed FY15 Site Safety Performance Summary and copy is uploaded to the SOP. - FY15 Site Safety Performance Summary includes the site Risk Focus's for FY15. - Copy of completed summary is displayed on the noticeboard.
If not compliant outline required action and transfer to Site Operational Plan as a Site Specific Action.
Question 7. First Aid Attendance Register First aid attendant register is current and each listed First aid Attendant has the following documents; A) Copy of their current first aid certificate. B) Signed confidentiality agreement. C) Signed Immunisation offer. (Refer SOP August FY14) To be compliant, all of the following must be satisfied; - Copy of current first aid certificates available for all first aid attendants. - Confidentiality Agreement signed by all first aid attendants. - Hepatitis B immunisation offer. - Site has adequate coverage to ensure minimum of one first Aider is maintained at all times.
If not compliant outline required action and transfer to Site Operational Plan as a Site Specific Action.
Question 8. Site Emergency Evacuation Drill Has site completed a Emergency Evacuation Drill every 6 months. (Refer SOP Oct FY14 and Apr FY14) To be compliant, all of the following must be satisfied; - Trial Evacuation has been completed on October and April with observers checklists and Team Activity Sheets uploaded to the SOP. - Any actions found from the evacuations have been transferred to the Site Operational Plan.
If not compliant outline required action and transfer to Site Operational Plan as a Site Specific Action.
Question 9. Target Chemical Register Target approved Chemical Register has been verified by site. Risk assessments for Dangerous goods are verified for those chemicals in use at site. Up to date MSDS's are maintained onsite for chemicals used. (Refer SOP Nov FY14) To be compliant, all of the following must be satisfied; - Current Target approved Chemical Register was verified in November FY14. Copy of plan is located in Risk Register under the Dangerous goods tab. - Current MSDS (<5 years old) are retained in folder for chemicals used onsite. - Completed Risk assessments for Dangerous goods are retained with MSDS.
If not compliant outline required action and transfer to Site Operational Plan as a Site Specific Action.
Question 10. Certificates and Registration for Plant and Equipment Verify the currency of Certificates/Registration (valid from and to dates) including but not limited to, your Lifts, Escalators, Cooling Towers, Pressure Vessels, Asbestos Review. (Refer to Target Development site under Maintenance & Compliance section for your site documents). To be compliant, all of the following must be satisfied; - Current certificates /registration for applicable items
If not compliant outline required action and transfer to Site Operational Plan as a Site Specific Action.
Question 11. Risk Register Using the SafetyCARE Risk Assessment Register the site has reviewed and identified risk assessments which are applicable. A tick should be placed next to any applicable risk assessments and the date the risk assessment was last reviewed. Where applicable the site has recorded any additional site specific controls. You have also reviewed the relevant risk assessments if the below following triggers where met: - Plant is introduced at Site (i.e. Bale Press) - Change to Workplace (I.e. refurbishment) - Following an incident at site - Incident trends Identified - New Site Manager - New Risk Assessment Published or - Risk Assessment last verified at site more than 5 years ago To be compliant, all of the following must be satisfied; - Completed Risk Assessment register. Verified Risk Assessments ONLY relate to equipment on site. - Filed Risk Assessment register with all verified Risk assessments applicable to site in a folder for easy future reference. Where applicable Site specific control added to the relevant Risk Assessment. - Site Manager has viewed completed Risk assessment verifications and countersigned.
If not compliant outline required action and transfer to Site Operational Plan as a Site Specific Action.
Question 12. Site Hazard Inspection Checklist (SHIC) SHIC's are been completed bi-monthly and all required fields on each page have been recorded. Note: It is preferable for sites to use the iauditor version on the ipad as it is quicker, easier to complete and allows for photos to be included. Any Low, Medium or High risk hazards identified have been rectified and comments against each L,M,H item on what action has been taken e.g. Fixed at time of inspection has been recorded on SHIC and in the SOP as a site specific action. To be compliant, all of the following must be satisfied; - Confirm that a completed SHIC has been uploaded to the SOP for past 12 months. - Each SHIC has been completed in full. Any action is recorded against identified issues, any outstanding actions are generated as a site specific action in the SOP.
If not compliant outline required action and transfer to Site Operational Plan as a Site Specific Action.
Question 13. Verified Log Book Store Responsibility section of the Verified Log Book system is completed prior to the 20th of each month and any gaps identified rectified. To be compliant, all of the following must be satisfied; - The Store Responsibility Section of the verified log book has been completed for past 12 months (Confirm by inspecting the site verified log book).
If not compliant outline required action and transfer to Site Operational Plan as a Site Specific Action.
Question 14. First Aid Kit Contents of First aid kits have been checked bi-monthly and replacement items ordered as required. To be compliant, all of the following must be satisfied; - Completed first aid checklists have been uploaded for each of the Site first aid kits using the Approved First Aid Content Checklist. (Check past 6 months worth of checks are completed as required)
If not compliant outline required action and transfer to Site Operational Plan as a Site Specific Action.
Question 15. Contractor Spot Checks Contractor Spot Checks are completed on a variety of Contractor and Supplier Representatives. Monthly Spot Checks have been completed and uploaded to the SOP. (Check past 6 months completed Spot Checks in the SOP to confirm). To be compliant, all of the following must be satisfied; - All fields in the Spot Checklist have been completed. - Corrective Action Reports (CARs) have been generated for all non conformances found.
If not compliant outline required action and transfer to Site Operational Plan as a Site Specific Action.
Question 16. National Safety Bulletin - Safe Storage of Items at Height (NSB 134) Site has actioned National Safety Bulletin no 134 (Safety Storage of Items at Height). (Refer SOP April FY14) Note: It has been observed that compliance to NSB134 has been variable within sites. To be compliant, all of the following must be satisfied; - Confirm that NSB 134 has been signed off by site manager and actions have been put in place. - Confirm the following is maintained at your site (physically view in back of house). - Review reserve areas to ensure heavy and bulky stock is not being stored at height. All items stored at height must able to be comfortably carried with one hand/arm. - Confirm that only reserve ladders are being used in reserve areas and are in a safe condition for use. Immediately tag Out of Service damaged or defective ladders and arrange for repair.
If not compliant outline required action and transfer to Site Operational Plan as a Site Specific Action.
Question 17. Formal Investigations Formal Investigation have been completed for all Medium and High risk Incidents and corrective actions completed. Investigations include a determination of what the root cause of the incident was and what corrective actions have been completed and what are required. To be compliant, all of the following must be satisfied; - Formal Investigations have been completed for all incidents rated as a Medium or High Risk. (Confirm that last 5 incidents rated as Medium of High Risk have a Formal Investigation attached in Part B of IRIS incident report). - Formal investigations clearly states the contributing factors to the incident, completed actions and the actions to be completed (Note: if actions not generated this is non compliant). - Actions to be completed have been added to the Site Operational Plan as a site specific action so they can be closed out.
If not compliant outline required action and transfer to Site Operational Plan as a Site Specific Action.
Question 18. Claim files are locked and kept confidential Ensure the team member claim files are kept in a locked cabinet with access limited to management. If no current claims, ensure there is a lockable cabinet available if the need arises. To be compliant, all of the following must be satisfied; - Observe location of files and ensure cabinet is locked or lockable
If not compliant outline required action and transfer to Site Operational Plan as a Site Specific Action.
Question 19. Claim files are maintained in accordance with Document Standards; Review claims files (closed or open) for compliance to the document standards To be compliant, all of the following must be satisfied; - Claims files comply with Document Standards.
If not compliant outline required action and transfer to Site Operational Plan as a Site Specific Action.
Question 20. Medical Certificates and RTW Plans Review open claims (if applicable) to ensure medical certificates are attached to Return to work plans for all periods where injured team members have partial capacity for work. I.e. all instances except unfit for work and fit for pre-injury duties on file at all times for the duration of the claim To be compliant, all of the following must be satisfied; - Certificates are attached to all Return to Work Plans. - Return to work plans are complete and signed.
If not compliant outline required action and transfer to Site Operational Plan as a Site Specific Action.
Question 21. Injury & Claim Grab Packs Injury & Claim Grab packs are compliant to the document standards and in a location that is easily accessible by management team. To be compliant, all of the following must be satisfied; - Grabs packs have been updated with InjuryCARE 1300 documents.
If not compliant outline required action and transfer to Site Operational Plan as a Site Specific Action.

Team Member Questionnaire

Question 1. Please explain what your "Duty of Care" is on your site?
Answer.
- Must take care of my own Health & Safety.
- Must co-operate with Target on safety matters. - Must not misuse equipment.
- Must not place self or others at Risk.
Team Member 1
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Team Member 2
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Team Member 3
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Team Member 4
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Team Member 5
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Comments. If responses demonstrate a Basic or No Knowledge level, outline required action below to improve awareness and transfer to Site Operational Plan as a Site Specific Action.
Question 2. Explain where you would find the “Our Health, Safety & Injury Management Policy”?

Answer.
Site Safety Notice Board
Team Member 1
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Team Member 2
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Team Member 3
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Team Member 4
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Team Member 5
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Comments. If responses demonstrate a Basic or No Knowledge level, outline required action below to improve awareness and transfer to Site Operational Plan as a Site Specific Action.
Question 3. Explain what you would do if you noticed a spill on your Site?

Answer.
- Ask another Team Member to obtain safety signage while you attend the spill. If no one is available or close by, place a carton, trolley or similar item over the spill while you obtain the signage.
- Always leave appropriate safety signage or barricading in place until the hazard is eliminated.
- If unsure of the nature of the spill, take all precautions and ensure you wear the following PPE items; gloves, eye protection and apron.
- Contact a Manager as soon as possible and safe to report Hazard.
Team Member 1
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Team Member 2
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Team Member 3
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Team Member 4
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Team Member 5
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Comments. If responses demonstrate a Basic or No Knowledge level, outline required action below to improve awareness and transfer to Site Operational Plan as a Site Specific Action.
Question 4. Explain what action you would take if a Safety issue was not resolved after raising it?

Answer.
- If the issue is not resolved it can be escalated to the Site Manager or Health & Safety Committee or Health and Safety Representative.
- If the issue is not resolved it can be escalated to the Regional Health & Safety Committee or Health & Safety Advisor.
- If the issue is not resolved it can be to National Committee or lastly WorkSafe or State Regulator.
- The Site has an "Health & Safety Issue Resolution Process" which should be followed.
Team Member 1
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Team Member 2
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Team Member 3
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Team Member 4
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Team Member 5
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Comments. If responses demonstrate a Basic or No Knowledge level, outline required action below to improve awareness and transfer to Site Operational Plan as a Site Specific Action.
Question 5. Explain what you would do in the case of an Emergency?

Answer.
- Remain Calm! When the Evacuation signal is given (EWIS (Whoop Whoop) or Code Orange is announced on PA, leave the building, escorting Customers, through the nearest and safest fire exit and go directly to the Site Assembly Area.
- Team Member to describe where location is (Manager to confirm)
- I would not collect any personal belongings.
- I would not use any escalators, lifts or travelators.
- I will remain at Assembly Area until further instructions from Chief Warden or Emergency Services.
Team Member 1
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Team Member 2
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Team Member 3
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Team Member 4
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Team Member 5
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Comments. If responses demonstrate a Basic or No Knowledge level, outline required action below to improve awareness and transfer to Site Operational Plan as a Site Specific Action.
Question 6. Explain what you would do if you injured yourself at work?

Answer.
Report the Injury to a Manager immediately and a Incident Report would be completed.
Team Member 1
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Team Member 2
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Team Member 3
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Team Member 4
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Team Member 5
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Comments. If responses demonstrate a Basic or No Knowledge level, outline required action below to improve awareness and transfer to Site Operational Plan as a Site Specific Action.
Question 7. Explain what InjuryCARE 1300 means?

Answer.
- InjuryCARE 1300 is an early intervention management program which incorporates a network of independent Doctors and is voluntary.
- The InjuryCARE 1300 Program provides Team Members with access to medical treatment and assist with the return to work as soon as possible (as medically appropriate).
- It includes access to a Nurse to provide immediate advice and support and where required to assist make an appointment with an InjuryCARE Doctor.
- The InjuryCARE Doctors and Physio's have a good understanding of our business and duties and working with a Manager can work through alternative tasks that may be suitable for me.
Team Member 1
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Team Member 2
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Team Member 3
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Team Member 4
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Team Member 5
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Comments. If responses demonstrate a Basic or No Knowledge level, outline required action below to improve awareness and transfer to Site Operational Plan as a Site Specific Action.

Manager Questionnaire

Question 1. Explain what your "Duty of Care" is as a Manager?

Answer
- Maintaing a Safe and Healthy Workplace for our Team Members, Customers, Contractors, Visitors and Neighbours.
- Ensure quick and effective injury management assistance to Team Members with work-related injury, illness or disability.
- Maintaining Safe Workplace (e.g. Provide a safe working environment, provide training, supervision, safe equipment).
- Ensuring contractors are following Target procedure.
Manager 1
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Manager 2
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Manager 3
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Comments. If responses demonstrate a Basic or No Knowledge level, outline required action below to improve awareness and transfer to Site Operational Plan as a Site Specific Action.
Question 2. Explain what action you would take if a Team Member reported a hazard to you?

Answer
- Resolve the Issue (if possible) and report it to your Site Manager. Provide Feedback to all Team Members involved with reporting.
- Refer to the Risk Assessment and ensure recommended controls are in place.
- If a Risk Assessment is not available contact the Regional Health & Safety Advisor.
- Follow Issue resolution process if issue can not resolved issue and continue to provide feedback to all Team Members on progress of resolution of hazard.
Manager 1
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Manager 2
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Manager 3
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Comments. If responses demonstrate a Basic or No Knowledge level, outline required action below to improve awareness and transfer to Site Operational Plan as a Site Specific Action.
Question 3. Explain what action you would take if the issue was not resolved after raising it?

Answer
- If the issue is not resolved it can be escalated to the Site Manager or Health & Safety Committee or Health and Safety Representative.
- If the issue is not resolved it can be escalated to the Regional Health & Safety Committee or Health & Safety Advisor.
- If the issue is not resolved it can be to National Committee or lastly WorkSafe or State Regulator.
- The Site has an "Health & Safety Issue Resolution Process" which should be followed.
Manager 1
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Manager 2
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Manager 3
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Comments. If responses demonstrate a Basic or No Knowledge level, outline required action below to improve awareness and transfer to Site Operational Plan as a Site Specific Action.
Question 4. Explain the "First Fifteen Minutes" Program?

Refer to First 15 minutes process for Answers.
Manager 1
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Manager 2
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Manager 3
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Comments. If responses demonstrate a Basic or No Knowledge level, outline required action below to improve awareness and transfer to Site Operational Plan as a Site Specific Action.
Question 5. Explain what action you would take if a Team Member reported receiving an Electric Shock from a piece of equipment?

Answer
- Disconnect the Power supply before assisting Team Member, never touch the person before doing this. Be mindful of area especially in bathrooms and wet areas.
- Arrange for someone to call 000 (triple zero) and when area is safe commence first aid.
- Site to be preserved and if required "made safe" by an Electrician.
- Contact your Regional Health & Safety Advisor who will contact the Regulator (WorkSafe) if required.
- Site to remain preserved until advised by Regional Health & Safety Advisor.
- Plug Lock and Out of Service Tag to be placed on equipment and equipment isolated. (Updated Out of Service Tag Register).
- Arrange for an assessment report to be obtained on equipment (through Assets Management Team).
- Contact Injury Managment Advisor and offer EAP to all relevant parties.
- Commence Formal Investigation with assistance of Regional Health & Safety Advisor.
Manager 1
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Manager 2
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Manager 3
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Comments. If responses demonstrate a Basic or No Knowledge level, outline required action below to improve awareness and transfer to Site Operational Plan as a Site Specific Action.
Question 6. Explain the processes in place to monitor hazards on your site?

Answer
- Site Hazard Inspection Checklist (SHIC).
- Safety Audits including Self Evaluation, Self Insurance Audits.
- Risk Assessments.
- Corrective Action Reports.
- Contractor Spot Checks.
- Consultation.
- Incident Reports.
- Formal Investigations.
- Site Opening and Closing Routines.
- Team Huddles.
Manager 1
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Manager 2
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Manager 3
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Comments. If responses demonstrate a Basic or No Knowledge level, outline required action below to improve awareness and transfer to Site Operational Plan as a Site Specific Action.
Question 7. Explain the process for signing in a Maintenance Contractor who is required to isolate power on your site?

Answer

- Contractor completes shaded section of sign in register.
- Contractor has valid induction card and work method statement for work.
- A high risk work permit is completed for works to be done (electrical work).
- Site Manger to complete and wear contractor lanyard until Contractor leaves site.
- Contractor fills in hazard update form for works to be done.
Manager 1
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Manager 2
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Manager 3
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Comments. If responses demonstrate a Basic or No Knowledge level, outline required action below to improve awareness and transfer to Site Operational Plan as a Site Specific Action.
Question 8. Explain the process you would take when new equipment or chemicals, changes to procedures or processes or changes to design of the site occur?

Answer
- Team Members must be consulted with before making changes to the workplace.
- This includes the verification of any accompaying Risk Assessments and completion of a Health andcompletion of Safety Consulation Feedback Form.
- Where a duly elected Health & Safety Representative is on site they must participate in all Consultation.
- Any Gaps should be escalated to relevant Support Function including Health & Safety Advisor.
- Information must be tabled at Site Safety Committee Meeting.
Manager 1
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Manager 2
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Manager 3
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Comments. If responses demonstrate a Basic or No Knowledge level, outline required action below to improve awareness and transfer to Site Operational Plan as a Site Specific Action.
Question 9. Explain your role during an emergency on your site?

Answer
- Ensure area allocated to Manager is clear.
- Follow directions from Chief Warden.
- Be familiar with Fire Extinguisher and their operation (if trained to do so) be familiar with all ECO code calls and ECO procedures.
Manager 1
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Manager 2
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Manager 3
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Comments. If responses demonstrate a Basic or No Knowledge level, outline required action below to improve awareness and transfer to Site Operational Plan as a Site Specific Action.
Question 10. Do you believe you have appropriate training in Health and Safety to complete your role?

Answer
- Yes or No - Site Manager to discuss actions to rectify gaps identified (if any)
Manager 1
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Manager 2
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Manager 3
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Comments. If responses demonstrate a Basic or No Knowledge level, outline required action below to improve awareness and transfer to Site Operational Plan as a Site Specific Action.
Question 11. Are you aware of the location of Injury and Claims Information Grab Pack/Folder?

Answer
- Team Member to name location specific to store.
Manager 1
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Manager 2
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Manager 3
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Comments. If responses demonstrate a Basic or No Knowledge level, outline required action below to improve awareness and transfer to Site Operational Plan as a Site Specific Action.
Question 12. When would you be required to utilise the Injury and Claims Information Grab Pack/Folder?

Answer
- When a Team Member reports a work-related injury and the injury requires medical attention.
Manager 1
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Manager 2
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Manager 3
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Comments. If responses demonstrate a Basic or No Knowledge level, outline required action below to improve awareness and transfer to Site Operational Plan as a Site Specific Action.
Question 13. What do you know about our requirement to demonstrate consultation with all stakeholders when developing RTW Plans?

Answer
- Consultation with the team member and employer are demonstrated through signatures on the plan and use of check boxes in distribution section. Consultation with Doctor is demonstrated through use of check boxes and treating practitioner fax coversheet. Doctor’s signature may also be included on plans if it has been returned. The InjuryCARE program is voluntary
Manager 1
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Manager 2
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Manager 3
- Over and Above Knowledge
- Good Knowledge
- Basic knowledge
- No knowledge
Comments. If responses demonstrate a Basic or No Knowledge level, outline required action below to improve awareness and transfer to Site Operational Plan as a Site Specific Action.

Self Evaluation FY15

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Target - Self Evaluation FY15

Instructions

What is a Self Evaluation?

Who completes a Self Evaluation?

When do you complete a Self Evaluation?

How do you complete a Self Evaluation?

What to do if you require assistance?

Self Evaluation Actions Section

Filing

SELF EVALUATION

Team Member Questionnaire

Manager Questionnaire

Related checklists

Self Evaluation FY15

Free Self Evaluation FY15 Checklist

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Target - Self Evaluation FY15

Instructions

What is a Self Evaluation?

Who completes a Self Evaluation?

When do you complete a Self Evaluation?

How do you complete a Self Evaluation?

What to do if you require assistance?

Self Evaluation Actions Section

Filing

SELF EVALUATION

Team Member Questionnaire

Manager Questionnaire

Related checklists