STOP! - TAKE 5

• Job Description

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

Complete the below questions

• I am fit for work

  Yes

  No

  Not Applicable

• I understand the task and steps required to complete this task safely

  Yes

  No

  Not Applicable

• I am trained and deemed competent for this task and the equipment required

  Yes

  No

  Not Applicable

• I know what to do in the event of an emergency

  Yes

  No

  Not Applicable

• My work will not impact others

  Yes

  No

  Not Applicable

• I have the correct tools and equipment for the task and they are fit for purpose

  Yes

  No

  Not Applicable

• I have the correct PPE for the task and it has been maintained in good condition

  Yes

  No

  Not Applicable

• All hazardous energy sources can be controlled, and I have listed them over page

  Yes

  No

  Not Applicable

• I have read and signed onto the relevant task risk assessment, procedure and/or permits

  Yes

  No

  Not Applicable

• Have you looked - ABOVE, BELOW, BEHIND, INSIDE?

  Yes

  No

  Not Applicable

If "No" to any of the above questions

• CONSULT YOUR SUPERVISOR - ADDITIONAL CONTROLS ARE REQUIRED

LIST HAZARDS & RISKS THAT HAVE BEEN IDENTIFIED

• What is the hazard or risk

• Has this been controlled to ALARP

  Safe

  At Risk

  N/A

• What is the hazard or risk

• Has this been controlled to ALARP

  Safe

  At Risk

  N/A

• What is the hazard or risk

• Has this been controlled to ALARP

  Yes

  No

  Not Applicable

• What is the hazard or risk

• Has this been controlled to ALARP

  Safe

  At Risk

  N/A

• What is the hazard or risk

• Has this been controlled to ALARP

  Safe

  At Risk

  N/A

• What is the hazard or risk

• Has this been controlled to ALARP

  Safe

  At Risk

  N/A