Site Specific Safety Plan

• Site Name

• Site Address

• Brief Description of Work

• Conducted on

  Date

• Prepared by

• Location
  Address

Notifications

• Does WorkSafe need to be notified of any onsite activities?

  Yes

  No

  N/A

• If yes, have you provided a copy of the notification (or receipt from WorkSafe)<br>with this agreement?

  Yes

  No

  N/A

Task Analysis

• If Switch is off then show

  Off

  On

• A job safety analysis is required for high risk work, for example: notifiable work, permit-to-work systems, work that requires a certificate of competence, as defined by regulation or when a risk assessment is undertaken resulting in critical or high level of risk for the job. For any new or complex activity, when it’s required by contract

• Is task analysis required for the activities covered by this agreement?

  Yes

  No

  N/A

• If yes, have you provided a copy (or copies) with this agreement?

  Yes

  No

  N/A

Hazard Management

• Have you provided a hazard register for activities on this site?

  Yes

  No

  N/A

• If no, has a hazard board been installed the site?

  Yes

  No

  N/A

Hazardous Products and Substances

• Will any hazardous products or substances be brought onto the site to perform<br>any agreed activities?

  Yes

  No

  N/A

• If yes, will products be recorded in a hazardous products and substances register?

  Yes

  No

  N/A

• If yes, will the relevant safety data sheets be available onsite?

  Yes

  No

  N/A

Communication Methods

• List weekly communication methods

  Select Pre-Start Meetings Toolbox Talks Weekly Meetings

  • Pre-Start Meetings
  • Toolbox Talks
  • Weekly Meetings

Inspection Methods

• List Inspection types

  Pre-Start Inspection

  Plant Inspections

  Weekly Site Inspections

  Safety Gear Inspections

Training & Competency Details

• If Switch is off then show

  Off

  On

• Every worker under our control on site will hold a current site safety card
  Every worker under our control on site will be given a job-specific safety induction
  Workers under our control on site will be appropriately qualified, competent, or fully supervised
  We will provide evidence of competency (on-site training and competency register) for any workers participating in the listed activities below

List activities that require training here

• List the activity?

• Unit standard?

• Or description of training taken and experience in order to undertake the task unsupervised?

Environmental Details

• Is there an environmental plan required for this site?

  Yes

  No

  N/A

• Is a resource consent required for any of the activities you will undertake<br>on this site?

  Yes

  No

  N/A

• If yes, is a copy of the consent attached to this SSSP?

  Yes

  No

  N/A

• Will dust or fumes or smoke be generated that could affect members of the<br>public or others in the vicinity?

  Yes

  No

  N/A

• If yes – Explain how this will be controlled?

• Will noise be generated that could affect members of the public or others in<br>the vicinity?

  Yes

  No

  N/A

• If yes – Explain how this will be controlled?

• Will your activity potentially cause dirty water or wash-down runoff, silt or other<br>contaminants to be released?

  Yes

  No

  N/A

• If yes – Explain how this will be controlled?

• Will vehicles or plant be refuelled on site?

  Yes

  No

  N/A

• If yes, what is the location of the designated refueling zone?

• And, how will fire, explosions, spills and waste be controlled?

Emergency Response Measures

List emergency response measures here

• Activity

• By Who (contracator)

Declaration

Contractor Declaration

• We have read the site specific safety plan information provided in this site specific work plan and agree to comply will all measures listed whilst working on the site for the duration of our contract

• Company Name?

• Responsible Person?

  Sign

Hazardous Substances Register

Substance

• Name of substance?

• Safety data sheet on site?

  Yes

  No

  N/A

• Related harm

  Select Explosive Flammable Corrosive Toxic Oxidising Harmful Irritant Biohazard Radioactive

  • Explosive
  • Flammable
  • Corrosive
  • Toxic
  • Oxidising
  • Harmful
  • Irritant
  • Biohazard
  • Radioactive

• List control measures here

Training and Competency Register

Personnel Details

• Name

• Key role or task?

• Qualifications?

• Years of experience?

Emergency Details

• Please note all contractors will be required to conduct their own roll calls if an on site emergency occurs
  Please ensure that all workers sign in and out of site on a daily basis

• Assembly point location?

• Responsible person?

• Contact telephone number?

• Emergency response signal (siren/bell etc)?

• First aider name?

• Contact telephone number?

• Location of first aid kit?