Title Page
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Site Name
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Site Address
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Brief Description of Work
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Conducted on
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Prepared by
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Location
Site Specific Requirements
Site Specific Health and Safety Agreement
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The address for this site agreement
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Brief outline of agree activities
This Agreement is between:
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PCBU
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Business Name
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Main contact on site
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Phone number
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Type of Business
- Main Contractor
- Client
- Principal
- Contractor
- Subcontractor
- Other
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If other list here
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On site safety representative
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Contact phone number
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First aid representive
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First aid representative phone number
Notifiable Works
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Does WorkSafe need to be notified of any onsite activities?
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If yes, have you provided a copy of the notification (or receipt from WorkSafe)<br>with this agreement?
Task Analysis/SWMS
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If Switch is off then show
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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
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Is task analysis required for the activities covered by this agreement?
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If yes, have you provided a copy (or copies) with this agreement?
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And, have you provided an emergency response plan?
Hazard and Risk Management
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Have you provided a hazard register for activities on this site?
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If no, has a hazard board been installed the site?
Hazardous Products and Substances
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Will any hazardous products or substances be brought onto the site to perform<br>any agreed activities?
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If yes, will products be recorded in a hazardous products and substances register?
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If yes, will the relevant safety data sheets be available onsite?
Communication Methods
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Toolbox Talks
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Frequency
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Project Pre-Start Briefings
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Frequency
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Daily Pre-Start Briefings
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Frequency
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Progress Meetings
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Frequency
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Other - Please List
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Frequency
Incident Reporting
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We agree to report these incidents immediately to PCBU 1 (Main principal/contractor) and a written report with 24 hours
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Serious injury
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Injury requiring first-aid
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Near miss - serious
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Near miss - minor
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Damage to plant/equipment/machinery (serious)
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We will report these incidents using
Inspection Methods
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We agree to carry out the following inspection and report the findings to PCBU 1 (principal/main contractor)
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Pre-Start Inspections
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Frequency
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By
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Site Inspections
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Frequency
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Days of Week
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
- Sunday
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Major Plant or Equipment Inspections
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Frequency
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Days of Week
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
- Sunday
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Vehicle Inspections
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Frequency
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Days of Week
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
- Sunday
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Specialist (MEWP/Cranes)
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Frequency
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Comment
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Other Inspections - Please List
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Frequency
- Before Start
- Daily
- Weekly
- Monthly
- Yearly
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Days of the Week
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
- Sunday
Training & Competency Details
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If Switch is off then show
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We agree that every worker under our control on site will hold a current site safety card
We agree that every worker under our control on site will be given a job-specific safety induction
We agree that every worker under our control on site will be appropriately qualified, competent, or fully supervised
For the agreed activities set out in this document, we will provide party 1 with evidence of competency (on-site training and competency register) for any workers participating in those activity types of activities (list below)
List activities that require training here
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List the activity?
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Competency Required
Environmental Details
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Is there an environmental plan required for this site?
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Is a resource consent required for any of the activities you will undertake<br>on this site?
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If yes, is a copy of the consent attached to this SSSP?
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Will dust or fumes or smoke be generated that could affect members of the<br>public or others in the vicinity?
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If yes – Explain how this will be controlled?
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Will noise be generated that could affect members of the public or others in<br>the vicinity?
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If yes – Explain how this will be controlled?
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Will your activity potentially cause dirty water or wash-down runoff, silt or other<br>contaminants to be released?
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If yes – Explain how this will be controlled?
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Will vehicles or plant be refuelled on site?
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If yes, what is the location of the designated refueling zone?
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And, how will fire, explosions, spills and waste be controlled?
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And, explain how you will manage construction waste?
Subcontractors to Party 2
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Subcontractors working on this site and not covered by this SSSP agreement must supply their own agreement
Emergencies
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We agree that we will respond to any emergencies as outlined in Party 1's Induction and emergency response plan
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If N/A, we agree to provide our won emergency response plan for this site
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We will need specialist equipment for an emergency response?
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If Yes, than please outline the equipment required
Equipment Required
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Equipment Description
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Provided By
Declaration (to be signed when agreement is reached)
PCBU 1 (principal/main contractor)
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We have read the Site-Specific Safety Plan information provided by Party 2 and agree that it is the appropriate approach to health and safety on this site for the duration of the contract
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Name/Signature
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Date
PCBU 2 (subcontractor)
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We agree to act according to the content of the Site-Specific Safety Plan as outline within this agreement
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Name/Signature
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Date
