Take 5 checklist

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Task description

Stop, Think and Prepare for the task

• 1. If a procedure or work instructions exists for the task, am I familiar with it?

  Yes

  No

• Description of the Hazard

• Controls put in place to reduce the risk

• 2. Am I fit for duties - free of fatigue and injuries, alert and not distracted i.e. is my mind on the task?

  Yes

  No

• Description of the Hazard

• Controls put in place to reduce the risk

• 3. Am I trained, competent and authorised for this task?

  Yes

  No

• Description of the Hazard

• Controls put in place to reduce the risk

• 4. Do I have fit for purpose tools, equipment and PPE?

  Yes

  No

• Description of the Hazard

• Controls put in place to reduce the risk

Identify Hazards

• 5. Can I strain or overexert, or am I in a poor ergonomic position?

  Yes

  No

• Description of the Hazard

• Controls put in place to reduce the risk

• 6. Will I be in the line of fire or caught in or between anything?

  Yes

  No

• Description of the Hazard

• Controls put in place to reduce the risk

• 7. Can I slip or trip on anything?

  Yes

  No

• Description of the Hazard

• Controls put in place to reduce the risk

• 8. Can I fall onto or from something?

  Yes

  No

• Description of the Hazard

• Controls put in place to reduce the risk

• 9. Can Something fall on me or someone else?

  Yes

  No

• Description of the Hazard

• Controls put in place to reduce the risk

• 10. Can I come into contact with hazardous substances

  Yes

  No

• Description of the Hazard

• Controls put in place to reduce the risk

• 11. Am I operating equipment near people, explosive or other equipment

  Yes

  No

• Description of the Hazard

• Controls put in place to reduce the risk

• 12. Could weather conditions/work environment affect this activity?

  Yes

  No

• Description of the Hazard

• Controls put in place to reduce the risk

• 13. Can I cause an impact to water, soil, air or community?

  Yes

  No

• Description of the Hazard

• Controls put in place to reduce the risk

• 14. Are there any other hazards? Have Energy Sources been considered?

  Yes

  No

• Description of the Hazard

• Controls put in place to reduce the risk

Preventive Controls

• 15. Do I require permit and appropriate certificates?

  Yes

  No

• Description of the Hazard

• Controls put in place to reduce the risk

• 16. Do I need isolate energy sources and test for dead?

  Yes

  No

• Description of the Hazard

• Controls put in place to reduce the risk

• 17. Is there a change to process, procedure, equipment or design?

  Yes

  No

• Description of the Hazard

• Controls put in place to reduce the risk

• 18. Do I need to conduct an inspection of any equipment prior to my commencing work?

  Yes

  No

• Description of the Hazard

• Controls put in place to reduce the risk

• 19. Do I need additional PPE for the task?

  Yes

  No

• Description of the Hazard

• Controls put in place to reduce the risk

• 20. Do I require positive communications to ensure others are aware of my presence and intentions?

  Yes

  No

• Description of the Hazard

• Controls put in place to reduce the risk