Take 5 Maintenance Daily Pre-Start

• Name

  Select
• Location
  Address

• Date

  Date

Stop and Think Through Today's Tasks

• Do I clearly understand what is required?

  Yes

  No

  N/A

• Am I trained to do the work and familiar with the equipment/task?

  Yes

  No

  N/A

• Are the tools and equipment in a safe condition?

  Yes

  No

  N/A

• Have I informed others who may be affected by my work?

  Yes

  No

  N/A

• Do I have the correct PPE/RPE for the task (identified in the risk assessment/method statement)?

  Yes

  No

  N/A

Identify and Assess the Hazards

• Identify any hazards

Hazard

• Hazard type

  Select Atmospheric Chemical Electrical Environmental General Gravitational Manual Handling Lighting Noise Pressure Radiation Thermal Other

  • Atmospheric
  • Chemical
  • Electrical
  • Environmental
  • General
  • Gravitational
  • Manual Handling
  • Lighting
  • Noise
  • Pressure
  • Radiation
  • Thermal
  • Other

• Please specify hazard type

• Take or attach photo evidence of hazard identified

  Media

• Describe the hazard

• Refer to image below for risk level

  

• Priority for action

  Extreme Risk

  High Risk

  Medium

  Low Risk

• Likelihood

  Almost Certain

  Likely

  Possible

  Unlikely

  Rare

• Control measure

Control and Monitor

• Are all hazards identified controlled or removed?

  Yes

  No

Completion

• Name & Signature of Assigned Employee

  Sign