Site Induction Form Employee & Contractor

• Project/Site

• Name

• Address

• Phone

• Project Number

• Company or Employer

• Emergency Contact

• Emergency Contact Phone

Skills & Licences

• Licences

• Certificates

• SWMS/JSA

• Trade/Occupation

• Immunisations

• This induction provides guidance and requirements regarding Re-Pump project sites for the Central Highlands Regional Council. All personnel will work through the site induction before commencing work at any of the sites for Central Highlands Regional Council. Visitors will not have to complete the site induction but will require a general visitor induction. https://www.linksafe.com.au/chrc/

• You agree to follow all requirements of the Workplace Health and Safety Act 2011, Workplace Health and Safety Regulations 2011, applicable Codes of Practice, and Industry Standards by: • Managing the safety of yourself and all others around you, including visitors, members of the public etc. • Following all aspects of SWMS, JSA, SWP, etc. • Do not proceed with unsafe activities that can potentially cause harm or injury to yourself or others, including members of the public. • Identify all workplace hazards that arise and the controls that apply to the particular hazards. Then, speak to a Re-Pump supervisor on-site to report hazards. • Immediately report any of the following to a Re-Pump Supervisor: o Injuries o Accidents o Workplace hazards o Environmental

• I have been made aware of Re-Pump site safety personnel on site and am aware that I must contact the person should a dangerous incident or defective plant and equipment arise. Re-Pump Project Manager – Andrew Buck – 0459 578 705 Re-Pump Site Supervisor – Kurt Nicholas – 0408 980 756

• I know my obligations to abide by the Environmental Act and legislation. • Immediately report any environmental incidents to Re-Pump Site Supervisor or Project Manager. • No littering on the site, near the site, or on any roads. • All work-related rubbish will be removed daily or as the Site Supervisor instructs. • No taps will be left running, and if there are dripping taps, report them to the Site Supervisor. • There is no drinking water from any taps on-site unless in the site office, admin building, control room, or shop purchasing (if applicable).

• I know my obligations to abide by the Environmental Act and legislation. • Immediately report any environmental incidents to Re-Pump Site Supervisor or Project Manager. • No littering on the site, near the site, or on any roads. • All work-related rubbish will be removed daily or as the Site Supervisor instructs. • No taps will be left running, and if there are dripping taps, report them to the Site Supervisor. • There is no drinking water from any taps on-site unless in the site office, admin building, control room, or shop purchasing (if applicable). • Use appropriate PPE as required, e.g. Gloves. • Re-Pump vehicles are fitted with a water tank, soap, and sanitiser. • On site water, soap and sanitiser is available (site office). • There are port a loos on site.

• I am aware that bullying, verbal, and physical abuse will not be tolerated on or near the site and could result in the removal of the project.

• Are there any known disabilities or physical conditions that could restrict work in any way (incl. suitable duties program, old injuries)?

  Yes

  No

  N/A

• Please List

• I must report any extenuating circumstances related to my health or well-being to my supervisor upon arrival at the site and/or during work hours.

• I have been inducted into my company’s safe systems of work, including all relevant SWMS for specific work, permits, and pre-starts for the project and the site-specific safety plant for each site. A SWMS or JSA must be filled out before commencing work on any site. In addition, the SWMS must be endorsed by Re-Pump’s site representative and Central Highlands Regional Council.

• I know I must only undertake work as stated by my employer. I will not undertake any work activities (including but not limited to working at heights, confined space, excavation, and trenching, demolition) or use any plant (including PPE) equipment or hazardous materials that I have not been authorised, trained, or deemed competent to do so.

• I am aware of the mandatory PPE requirements for the site/s, and that failure to comply with PPE requirements may result in a safety breach being issued. Site requirements are: • Hard Hats • High visibility clothing • Long sleeve shirts and long trousers • Steel capped boots • PPE Requirements as directed by the SWMS (e.g. Safety glasses, earmuffs, masks, gloves)

• I am aware that I must report all incidents, injuries, near misses, and environmental (no matter how minor) to the Supervisor, Project Manager, or WHSE Manager immediately upon becoming aware of them and that failing to do so may result in non-acceptance of a claim or a safety breach may be issued.

• I have been advised of the emergency procedures relating to the site, the location of the emergency evacuation and assembly points, emergency personnel, including first aid attendants, the location of the nearest off-site medical centre, and the location of the firefighting equipment, and have been instructed in the correct and safe use of equipment. Project Manager – Andrew Buck – 0459 578 705 Site Supervisor – Kurt Nicholas – 0408 980 756 Ambulance, Fire, Police: 000 Doctor – North Blackwater General Practice – 4896 1179 Snake Catcher – Central Highlands Regional Council - 1300 242 686

• I have been advised of the site layout, including: • Vehicle traffic routes – Traffic Management Plan attached • Pedestrian walkways - Traffic Management Plan attached • Restricted areas (if applicable) – Traffic Management Plan attached • Exclusion zones (if applicable) - Traffic Management Plan attached • Deliveries – Traffic Management Plan attached • Locations of amenities – Port a loo on site. • Safety notice board (if applicable) Site Office • First Aid Facility – Site Office • Snake Bite Kit – Site Office • Emergency Assembly Areas – Traffic Management Plan attached • Trenching and excavation – I have signed onto the trenching and excavation SWMS. • Demolition – I have signed onto the Demolition SWMS

• I must attend toolbox talks and training associated with my trade or work area where required.

• I have been inducted into my company’s safe systems of work, including all relevant SWMS for specific work, permits, and pre-starts for the project and the site-specific safety plant for each site. A SWMS or JSA must be filled out before commencing work on any site. In addition, the SWMS must be endorsed by Re-Pump’s site representative and Central Highlands Regional Council.

• I know I must only undertake work as stated by my employer. I will not undertake any work activities (including but not limited to working at heights, confined space, excavation, and trenching, demolition) or use any plant (including PPE) equipment or hazardous materials that I have not been authorised, trained, or deemed competent to do so.

• I am aware of the mandatory PPE requirements for the site/s, and that failure to comply with PPE requirements may result in a safety breach being issued. Site requirements are: • Hard Hats • High visibility clothing • Long sleeve shirts and long trousers • Steel capped boots • PPE Requirements as directed by the SWMS (e.g. Safety glasses, earmuffs, masks, gloves)

• I am aware that I must report all incidents, injuries, near misses, and environmental (no matter how minor) to the Supervisor, Project Manager, or WHSE Manager immediately upon becoming aware of them and that failing to do so may result in non-acceptance of a claim or a safety breach may be issued.

• I have been advised of the emergency procedures relating to the site, the location of the emergency evacuation and assembly points, emergency personnel, including first aid attendants, the location of the nearest off-site medical centre, and the location of the firefighting equipment, and have been instructed in the correct and safe use of equipment. Project Manager – Andrew Buck – 0459 578 705 Site Supervisor – Kurt Nicholas – 0408 980 756 Ambulance, Fire, Police: 000 Doctor – North Blackwater General Practice – 4896 1179 Snake Catcher – Central Highlands Regional Council - 1300 242 686

• I have been advised of the site layout, including: • Vehicle traffic routes – Traffic Management Plan attached • Pedestrian walkways - Traffic Management Plan attached • Restricted areas (if applicable) – Traffic Management Plan attached • Exclusion zones (if applicable) - Traffic Management Plan attached • Deliveries – Traffic Management Plan attached • Locations of amenities – Port a loo on site. • Safety notice board (if applicable) Site Office • First Aid Facility – Site Office • Snake Bite Kit – Site Office • Emergency Assembly Areas – Traffic Management Plan attached • Trenching and excavation – I have signed onto the trenching and excavation SWMS. • Demolition – I have signed onto the Demolition SWMS

• I must attend toolbox talks and training associated with my trade or work area where required.

• All people who enter the site must: • Be inducted to the Dingo site/s • Sign in and sign out whilst undertaking work on behalf of Re-Pump

• I have been advised that all electrical equipment must be “Tested and Tagged” every three months on site. If it is not tagged or out of date, it is to be: • Tagged out and no longer used • Notified the supervisor or Re-Pump representative. Note: RCDs should be used and are to be connected straight to the power outlet. All leads will be hung off the ground and in or near walkways, including pedestrian areas and parks.

• I have been advised that only licenced persons are authorised to work on any electrical leads, equipment, cabling, tools, lighting or plant and, if unsure, to treat all electrical cabling as “live”.

• I am aware that there will be demolition on site and have singed onto the SWMS. I am aware of the hazards incl: • Hazardous materials (eg. Asbestos or lead, crystalline silica) • Noise • Flying debris • Broken bones • Burns • Vibration • Dust • Slips, trips, and falls from loose debris.

• I have been trained in the correct manual handling techniques (including team lifting) relevant to my work.

• I am aware that there will be excavation and trenching of 1.5m and have signed onto the SWMS. I am aware of the hazards incl: • Falling into the trench • Tripping over rocks etc. • Pedestrians • Other workers

• I am aware of the hazardous area around the site, and I have completed hazardous awareness training.

• I am aware that there will be moving heavy equipment around site. I am aware of the hazards that incl: • Being struck by equipment • Flying objects • Falls from equipment • Electrocution (look up and live) • Crushed or caught between machinery • Equipment rollover or tipping

• I am aware that there are hazardous chemicals on site. I am aware of the hazards that incl: • Spills (emergency evacuation) • Burns • Inhalation • Irritation • Exposure

• I agree to abide by all site requirements stipulated by Re-Pump and to comply with my obligations under OHS/Environmental legislation in the interest of myself, fellow workers, site visitors, and the general public.

Sign Off

• Full Name

• Signature

  Sign
• Add location
  Address

• Select date

  Date

Supervisor Sign Off

• I have/have not sighted the person’s induction card and other relevant licences and certificates, etc.

  Yes

  No

  N/A

• Full Name

• Position

• Signature

  Sign