Title Page

  • Site conducted

  • Conducted on

  • Company

  • Prepared by

  • Location
  • Sheet No.

  • Asset ID


  • Have you Completed a SWMS?

  • Are there any hazards not identified by the work instruction?

  • please list risks and your controls

  • Does the site require WZTM?

  • Please note the field book reference

  • take photo of plan or actual set up

  • take photo of work zone


  • Asset ID

  • photo of valve or fireplug before works

  • location, please select as close a possible to the manhole on map
  • depth to road surface from mounting plate

  • can plate be mounted

  • take photo

  • please take photo of installed plate

  • Has site been tidied and left in a safe manner?

  • take photo of tidied site before leaving

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.