SHE Leadership Visit Record

• SHE Leadership Visit Record Title (include project, location, etc.)

• Document No. VS-HS-HSC-037 Issue 1

• Conducted on

  Date

• Project

• Conducted by

• Work activity

• Location
  Address

• Personnel / Contractors Visited

Telecommunications Safety Essentials

• 1.1 Does work involve working with electricity?

  Yes

  No

• Above the line controls/comments

• 1.2 Can work result in a fall of more than two metres?

  Yes

  No

• Above the line controls/comments

• 1.3 Does work require workers to drive longer than two hours?

  Yes

  No

• Above the line controls/comments

• 1.4 Are workers required to work in the vicinity of overhead/underground utilities?

  Yes

  No

• Above the line controls/comments

• 1.5 Does work involve excavation works or require persons to work in excavations deeper than 1.5m?

  Yes

  No

• Above the line controls/comments

• 1.6 Is the worksite in the vicinity of vehicular traffic?

  Yes

  No

• Above the line controls/comments

• 1.7 Are workers required to work in or around mobile plant?

  Yes

  No

• Above the line controls/comments

• 1.8 Are workers required to work in remote or isolated locations?

  Yes

  No

• Above the line controls/comments

• 1.9 Does work involve heavy lifting (>75% safe working limit) using a crane or mobile plant?

  Yes

  No

• Above the line controls/comments

• 1.10 Are workers exposed to asbestos?

  Yes

  No

• Above the line controls/comments

Environmental Impacts

• 2.1 Noise / air pollution

  Yes

  No

• Comments

• 2.2 Fire management

  Yes

  No

• Comments

• 2.3 Vehicle wash down

  Yes

  No

• Comments

• 2.4 Cultural heritage

  Yes

  No

• Comments

• 2.5 Waste management

  Yes

  No

• Comments

• 2.6 Erosion and sediment control

  Yes

  No

• Comments

• 2.7 Vegetation clearance / reinstatement

  Yes

  No

• Comments

• 2.8 Land access

  Yes

  No

• Comments

• 2.9 Prescribed waste disposal

  Yes

  No

• Comments

• 2.10 Spill management

  Yes

  No

• Comments

• 2.11 Fauna / flora

  Yes

  No

• Comments

• 2.12 Noxious weeds / insects

  Yes

  No

• Comments

Topics Discussed

• 3.1 Is the SHEWMS current and available?

  Yes

  No

• Comments

• 3.2 Were workers wearing the appropriate PPE?

  Yes

  No

• Comments

• 3.3 Were any significant safety breaches observed?

  Yes

  No

• Comments

• 3.4 Is there evidence of the latest Telecommunications safety information being received?

  Yes

  No

• Information received / comments

• 3.5 Were safety or environmental topics discussed?

  Yes

  No

• Topics discussed / comments

Comments / Corrective Actions

• Are there any further comments or corrective actions required? (Corrective actions must be assigned to action owner in Cintellate)

  Yes

  No

• Comments / corrective actions

Sign-off

• Person completing visit

  Sign

• Select date

  Date