SITE SPECIFIC CHECKLIST

• Work Order number

• Site

• Conducted on

  Date

• Prepared By

  Select Stephen Wilmot Cameron Lewis Gordon Lockeridge Andre Dangaard Mathew Hawkins Les Golden Cameron Macaulay Susan Martello

  • Stephen Wilmot
  • Cameron Lewis
  • Gordon Lockeridge
  • Andre Dangaard
  • Mathew Hawkins
  • Les Golden
  • Cameron Macaulay
  • Susan Martello
• Location
  Address

• Personnel on site

  Select Stephen Wilmot Cameron Lewis Gordon Lockeridge Andre Dangaard Mathew Hawkins Les Golden Cameron Macaulay Susan Martello

  • Stephen Wilmot
  • Cameron Lewis
  • Gordon Lockeridge
  • Andre Dangaard
  • Mathew Hawkins
  • Les Golden
  • Cameron Macaulay
  • Susan Martello

General

• Work Type

  Mowing

  Groundwork

  Garden Work

  Spraying

  Other

• Site Conditions

  Fine

  Rain

  Wind

  Extreme Heat

• Is the site safe for duties being performed?

  Safe

  At Risk

  N/A

• Location Type

  Park

  Nature Strip

  Other

• Equipment Required

  Select PPE Front Deck Mower Small Plant Spray Equipment Hand Tools Loader Push Mower

  • PPE
  • Front Deck Mower
  • Small Plant
  • Spray Equipment
  • Hand Tools
  • Loader
  • Push Mower

Hazard Assessment

• Have the Pre Start Checks been undertaken on all machinery? *List any issues*

  Yes- Machine is working correctly

  No- Machine needs maintenance

• Are your tools, equipment and chemicals safely stored while not in use on site?

  Yes - Secured appropriately on vehicle

  No- Unable to secure

  N/A

• Unsecured equipment can be stolen or be a safety issue.

• Pedestrian Control

  Yes- appropriate controls in place

  No - No controls are in place

  Controls not required

• Pedestrians and users of the area should be aware of your activities and be safe while in the area.

  

• Vehicular Traffic

  Yes- appropriate controls in place

  No - No controls are in place

  Controls not required

• Be aware of vehicles on the road and within parks.

  

Toolbox Discussion

• Is there more than one worker on site?

  Yes- Crew on site

  No- Working alone

• If more than one worker on site list who is performing what duties in the notes.

• PPE REQUIRED

  Select CHEMICAL PROTECTION HEARING PROTECTION EYE PROTECTION LEG PROTECTION SUN PROTECTION OTHER

  • CHEMICAL PROTECTION
  • HEARING PROTECTION
  • EYE PROTECTION
  • LEG PROTECTION
  • SUN PROTECTION
  • OTHER

• Have SWMS been read and understood by all on site?

  Yes

  No

  N/A

• Emergency numbers
  Police/Fire/Ambulance. 000
  Supervisor. 0412496345
  Manager. 0434567724

• Name:

  Sign

• Name:

  Sign

• Name:

  Sign