Information

  • Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

SITE SPECIFIC INFORMATION

  • Ref:

  • Date Of Survey

  • Site address

  • Building Description

  • Surveyor

  • Ref:

  • Requested By:

  • Ref No.

  • PO Number

  • Reference No.

  • Date Of Survey

  • Client Contact Name

  • Client Contact Number

  • Pre Advised Site Access Comments

Delivery Crew Options

  • Does this delivery/installation require a crew

  • How many crew members

  • Estimated time to complete

Vehicle

  • What Type of Vehicle Required

Security Clearance

  • Are special permits/passes/keys required?

  • Are Vehicle & Driver details required

  • Security X Clearance required

  • Is the delivery/installation out of hours?

  • At what time will this take place

Equipment Details

  • Description of Equipment: (BOX ID)

  • PID:

  • Dimensions

  • Width D

  • Depth

  • Height

  • Weight

  • Quantity

Final Placement Location

  • Has the client indicated that advance notice is required?

  • Hours of access

  • From (time)

  • To (Time)

Site Preparation

  • Unloading area to final placement

  • Is the the equipment FINAL location Ground, 1st Floor?

  • Estimated distance from unloading area

  • If the installation is NOT ON THE GROUND FLOOR, what equipment is to be used

  • Equipment to be used

  • Complete if Lift is being considered

  • Photograph of Lift

  • Can lift be used for equipment/consumables?

  • Dimensions of the Lift (L'W'H)

  • Maximum load of lift (Kgs)

  • Maximum opening size of Lift Doors (H'W)

  • Complete if Stairwalker is being considered

  • Number of flights of Stairs & Steps per flight

  • Number of landings

  • Are the stairs & Landings wide enough for a Stairwalker to be used

  • Photograph of Staircase

  • Rough Sketch and sizes

  • What are the dimensions of any doors along the delivery route

  • How many doors along the route

  • Is the way clear of any obstruction and large enough for the passage of equipment

  • Photograph of any possible obstructions

  • Rough Sketch of any obstructions with dimensions

Specialist Equipment required

  • List all equipment required

  • Select Specialist Equipment

  • Select Specialist Equipment

  • Select Specialist Equipment

  • Select Specialist Equipment

  • Select Specialist Equipment

  • Select Specialist Equipment

  • Select Specialist Equipment

  • Select Specialist Equipment

  • Select Specialist Equipment

  • Select Specialist Equipment

  • Select Specialist Equipment

  • Select Specialist Equipment

  • Select Specialist Equipment

  • Select Specialist Equipment

  • Select Specialist Equipment

  • Select Specialist Equipment

  • Select Specialist Equipment

  • Select Specialist Equipment

  • Select Specialist Equipment

  • Select Specialist Equipment

  • Other Specialised Equipment specify

Health & Safety

  • Has a site risk assessment been carried out by the Client

  • Has the client shown supplied a copy of the site risk assessment?

  • ACTIONS REQUIRED BY CLIENT

  • Action required by client

  • ACTIONS THAT BST NEEDS TO UNDERTAKE

  • Action required by BST

  • Scope of Work & Method

  • Describe how the equipment will be taken from point A to point B; from the 'unloading area' to its 'final destination'. Highlight any potential obstructions on route

  • Surveyors name

  • Signature

  • Date & Time

Risk Assessment

  • HAZARD IDENTIFICATION

  • Hazards that are relevant to the installation must be assessed against the possibility of Occurrence of injury and the severity of the injury, and are scored between 1 & 5. The values are then multiplied together to obtain a risk rating

  • POSSIBILITY OF (P)

  • 1 = The incident is almost certain NOT to occur, only happening in exceptional circumstances

  • 2 = Unlikely

  • 3 = There is a possibility of it occurring if an additional factor triggers it

  • 4 = Likely

  • 5 = There is almost a 100% chance of the incident occurring

  • SEVERITY OF (S)

  • 1 = Minor injury, for example a small knock that does not require first aid

  • 2 = An accident requiring first aid

  • 3 = A serious accident, e.g. A broken bone

  • 4 = A major injury resulting in a number of days off work

  • 5 = Death

RISK RATING - A HAZARD WITH A RISK RATING OF 6 OR ABOVE, OR A POSSIBILITY OF SEVERITY OF SCORE 5 REQUIRES IMMEDIATE CORRECTIVE ACTION

TRIP HAZARD

  • HAZARD

  • Trip Hazards - Examples include pipe work, cabling,obstructions, work being carried out by other contractors

  • Possibility of (P)

  • Severity of (S)

  • Risk Rating

  • Picture of Hazard

  • Action required

SLIP HAZARD

  • HAZARD

  • Slip Hazard - example include wet flooring, oil, mud, ice etc

  • Possibility of (P)

  • Severity of (S)

  • Risk Rating

  • Picture of Hazard

  • Action required

FALLING OBJECT HAZARD

  • HAZARD

  • Falling Objects Hazard - Are there people working overhead, leaks from overhead pipes etc.

  • Possibility of (P)

  • Severity of (S)

  • Risk Rating

  • Picture of Hazard

  • Action required

ILLUMINATION HAZARD

  • Hazard

  • Illumination Hazard - Is there inadequate illumination to conduct work safely,is more light required

  • Possibility of (P)

  • Severity of (S)

  • Risk Rating

  • Action required

FIRE HAZARD

  • HAZARD

  • Fire Hazard - Presence of flammable materials, e.g. Paints, waste materials etc.

  • Possibility of (P)

  • Severity of (S)

  • Risk Rating

  • Action required

NOISE FROM SITE SERVICES

  • HAZARD

  • Noise from Site Services - Presence of air conditioning units, activities of other contractors or employees

  • Possibility of (P)

  • Severity of (S)

  • Risk Rating

  • Action required

EXPOSURE TO DISEASE

  • HAZARD

  • Exposure to Disease Hazard - Examples include Weil's Disease from rats urine & Lyme's Disease from Tick bites

  • Possibility of (P)

  • Severity of (S)

  • Risk Rating

  • Action required

EXPOSURE TO HAZARDOUS SUBSTANCES

  • HAZARD

  • Exposure to Hazardous Substances - Examples include asbestos, chemicals, biological agents, fibreglass insulation etc.

  • Possibility of (P)

  • Severity of (S)

  • Risk Rating

  • Action required

HAZARDS TO EMPLOYEES FROM OTHER TRADES WORKING ON SITE

  • HAZARD

  • Hazards to employees from other trades working on site

  • Possibility of (P)

  • Severity of (S)

  • Risk Rating

  • Action required

RISK OF FALLING

  • HAZARD

  • Risk of Falling Hazard - Examples include working at height, working in areas that cannot support weight, e.g. Roofs, etc.

  • Possibility of (P)

  • Severity of (S)

  • Risk Rating

  • Action required

ROADSIDE WORKING

  • HAZARD

  • Roadside Working Hazard - Are the crews working on or near a road? Is there any Traffic Management

  • Possibility of (P)

  • Severity of (S)

  • Risk Rating

  • Action required

MANUAL HANDLING

  • HAZARD

  • Manual Handling Hazards - Lifting of any description

  • Possibility of (P)

  • Severity of (S)

  • Risk Rating

  • Risk Rating

  • Action required

  • ********** IMPORTANT NOTICE ********** This risk assessment part of the site survey has to be reviewed in at least 3 months or in the case of changes in the work situation (activity, environment, equipment etc) or in legislation

  • Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.