Take 5 Draft Copy

• Take 5 ID No:

• Task Description:

• Vessel/ Site Name

• Conducted on

  Date

• Completed by - Name:

• Completed by - Rank:

START

• Do I fully understand the task?

  Yes

  No

• STOP!!!
  Speak with your supervisor - you cannot assess a task you do not fully understand.

• Does the task involve any of the following?

  Select Confined / Enclosed Space Entry Hot Work Electrical Work (requiring isolation) Mechanical Work (requiring isolation) Diving Work Work with Pipelines or Pressure (requiring isolation) Work at Heights Other high risk work as defined in the Permit to Work Procedure None of these

  • Confined / Enclosed Space Entry
  • Hot Work
  • Electrical Work (requiring isolation)
  • Mechanical Work (requiring isolation)
  • Diving Work
  • Work with Pipelines or Pressure (requiring isolation)
  • Work at Heights
  • Other high risk work as defined in the Permit to Work Procedure
  • None of these

• PTW Required - Enter PTW Number

• Is the equipment I am using (including PPE) in good working order and appropriate to task?<br>(E.g current test and tag, etc.)

  Yes

  No

• STOP!! Don’t use faulty or inappropriate equipment or PPE! (List detail for repair/ correction needed)

• Do I have all the necessary (current) training and qualifications to complete the task?

  Yes

  No

  I don’t know

  I will be under the supervision of a qualified person

• Enter name and rank of competent person supervising

• STOP!! Don’t perform work you are not trained/competent/ qualified for!
  Speak to your supervisor

• Was my task discussed in a Toolbox Talk today?

  Yes

  No

• ENTER TIME OF TBT:

Situational Awareness

• 1. Can I be caught in, on or between anything?

  Yes

  No

• SUMMARY OF HAZARD CONTROLS:

• YOU CAN USE PREVIOUS STEP NUMBERS TO REFER TO CONTROLS ALREADY LISTED!

• 2. Can I strain or over exert myself? Or will I be working in an awkward position?

  Yes

  No

• SUMMARY OF HAZARD CONTROLS:

• YOU CAN USE PREVIOUS STEP NUMBERS TO REFER TO CONTROLS ALREADY LISTED!

• 3. Can I fall into/ onto/ from anything?

  Yes

  No

• SUMMARY OF HAZARD CONTROLS:

• YOU CAN USE PREVIOUS STEP NUMBERS TO REFER TO CONTROLS ALREADY LISTED!

• 4. Can something fall onto me?<br>(E.g falling equipment/ projectiles/ mobile plant)

  Yes

  No

• SUMMARY OF HAZARD CONTROLS:

• YOU CAN USE PREVIOUS STEP NUMBERS TO REFER TO CONTROLS ALREADY LISTED!

• 5. Can I slip or trip on anything?

  Yes

  No

• SUMMARY OF HAZARD CONTROLS:

• YOU CAN USE PREVIOUS STEP NUMBERS TO REFER TO CONTROLS ALREADY LISTED!

• 6. Could the work I am doing pose a danger to others?<br>(e.g. could drop objects/ cause objects to fall/ cause slip, trip or fall hazard/ block emergency exit points or thoroughfare/ cause exposure risk to others?)

  Yes

  No

• SUMMARY OF HAZARD CONTROLS:

• YOU CAN USE PREVIOUS STEP NUMBERS TO REFER TO CONTROLS ALREADY LISTED!

• 7. Are there any objects/equipment/processes that could result in lacerations

  Yes

  No

• SUMMARY OF HAZARD CONTROLS:

• YOU CAN USE PREVIOUS STEP NUMBERS TO REFER TO CONTROLS ALREADY LISTED!

• 8. Are others doing work nearby that could pose a risk to me?<br>(Including overhead and below deck)

  Yes

  No

• SUMMARY OF HAZARD CONTROLS:

• YOU CAN USE PREVIOUS STEP NUMBERS TO REFER TO CONTROLS ALREADY LISTED!

• 9. Is there a contact or exposure risk?<br>(e.g. electricity, extreme temperatures, gas, stored energy, hazardous substances, radiation, noise, biological or chemical hazards)

  Yes

  No

• SUMMARY OF HAZARD CONTROLS:

• YOU CAN USE PREVIOUS STEP NUMBERS TO REFER TO CONTROLS ALREADY LISTED!

• 10. Is there a chance I could spill something, or otherwise pollute, damage or disturb the environment?

  Yes

  No

• SUMMARY OF HAZARD CONTROLS:

• YOU CAN USE PREVIOUS STEP NUMBERS TO REFER TO CONTROLS ALREADY LISTED!

• 11. Is there a risk from the weather/sea/working environment/ lighting conditions, which could affect job safety?

  Yes

  No
• Add location
  Address

• SUMMARY OF HAZARD CONTROLS:

• YOU CAN USE PREVIOUS STEP NUMBERS TO REFER TO CONTROLS ALREADY LISTED!

• 12. Will I be working in a high (damaging) noise area?

  Yes

  No

• SUMMARY OF HAZARD CONTROLS:

• YOU CAN USE PREVIOUS STEP NUMBERS TO REFER TO CONTROLS ALREADY LISTED!

• 13. Are there any other hazards present?

  Yes

  No

• SUMMARY OF HAZARD CONTROLS:

• YOU CAN USE PREVIOUS STEP NUMBERS TO REFER TO CONTROLS ALREADY LISTED!

PPE CONTROLS

• Is PPE Required according to the matrix, or is listed as hazard control?

  Yes

  No

• Specify Required PPE:

FINISH

• (Tick) I have considered my task and believe the controls listed to be effective in allowing me to safely complete my task

• Signature

  Drawing