Information
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Location
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Conducted on
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Prepared by
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Personnel
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Task description
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HIGH RISK WORK
HIGH RISK WORK
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Excavations
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Permit to work completed correctly?
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Excavation permit completed correctly?
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Dial Before You Dig acquired and understood?
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Site drawings acquired and understood?
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Working at heights
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Permit to work completed correctly?
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Working at heights permit completed correctly?
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Asbestos removal
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Permit to work completed correctly?
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Asbestos Removal Control Plan completed correctly?
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Hot works
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Permit to work completed correctly?
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Hot works permit completed correctly?
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Confined space
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Permit to work completed correctly?
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Confined space permit completed correctly?
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Electrical/HV
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Permit to work completed correctly?
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RISK ASSESSMENTS
RISK ASSESSMENTS
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Take 5
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Completed correctly?
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Hazard ID effective?
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Controls successfully implemented?
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JHA
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Completed correctly?
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Hazard ID effective?
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Controls successfully implemented?
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SWP
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Read and understood by worker?
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Signed onto by worker?
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Referenced in JHA?
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Guidelines followed and controls implemented?
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HOUSEKEEPING & SITE SETUP
HOUSEKEEPING & SITE SETUP
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Site box in place and correctly set up?
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Access to site clear?
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Site barricading sufficient?
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Sufficient signage in place?
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Site secured when unattended?
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Materials and equipment neatly organised?
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Waste materials being correctly dealt with?
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CHEMICALS
CHEMICALS
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Chemicals on approved list?
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MSDS available for each product?
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Storage method compliant?
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Waste disposal methods suitable?
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Chemicals correctly labelled?
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Correct PPE implemented as per MSDS?
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PPE
PPE
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Clothing and body protection required?
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Correctly implemented?
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Eyewear / face protection required?
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Correctly implemented?
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Head protection required?
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Correctly implemented?
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Hearing protection required?
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Correctly implemented?
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Protection class
- 3
- 5
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Respiratory protection required?
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Implemented?
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Fit test completed?
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User clean shaven and adhering to facial hair policy?
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Model used?
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Filter used:
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Correct for task?
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Correct for task?
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Gloves required?
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Correctly implemented?
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MANUAL HANDLING
MANUAL HANDLING
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Task
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Description
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Mechanical aids used
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Back
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Risk level
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Shoulders
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Risk level
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Arms
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Risk level
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Legs
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Risk level
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USE OF PLANT / EQUIPMENT
USE OF PLANT / EQUIPMENT
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Portable power tools
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Tools used
- Drill
- Skill saw
- Drop saw
- Planer
- Sander
- Other
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Prestart check completed?
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Operator competent?
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Hand tools
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Prestart check completed?
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Operator competent?
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Concrete saw
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Prestart check completed?
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Operator competent?
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Jackhammer
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Prestart check completed?
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Operator competent?
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Angle grinder
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Prestart check completed?
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Operator competent?
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Other
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Description
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Prestart check completed?
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Operator competent?
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VEHICLES & MACHINERY
VEHICLES & MACHINERY
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Vehicle / machine inspection
Vehicle
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Description
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Correctly parked?
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Prestart check completed?
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Mechanically sound?
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Vehicle file complete and current?
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Machine use?
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Machines used
- Excavator
- Backhoe
- Skid steer
- Forklift
- Potholing machine
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Operator competent?
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Operated safely?
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Spotter in place?
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ACTIONS & GENERAL COMMENTS
ACTIONS & GENERAL COMMENTS
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Action
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Description
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By whom?
General comments
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Comment:
