TAKE 5 - Prestart Check

• Please stamp the "Take 5" start time

  Date
• Location
  Address

• Enter your First & Last Name

• Enter Initials of persons with you or "NA" if single person crew.

PRE-START CHECKLIST - The following are mandatory for Field Based work with CiS International

• Check you have these before you leave for work. These items are mandatory for compliance to CiS HSE Field Work.

  Select Have a copy of SWMS with you Safety Footwear - AS / NZ 2210 Hi Vis Vest/Clothing First Aid Kit You have read and understood the SWMS for today's work You have adequate sun protection Carrying CIS ID and White Card

  • Have a copy of SWMS with you
  • Safety Footwear - AS / NZ 2210
  • Hi Vis Vest/Clothing
  • First Aid Kit
  • You have read and understood the SWMS for today's work
  • You have adequate sun protection
  • Carrying CIS ID and White Card

• Have you checked the weather? Please ensure you have the adequate PPE and understand what measures to take to work to the weather conditions? I.e. If very hot, take short breaks in the shade and sip water regularly.

  Yes

  No

• Are you and other persons working with you fit, well rested and able to work safely today? (see SWMS 'Pre Start Check')

  Yes

  No

PLANNED ACTIVITIES - The following helps you plan better and ensure you have the adequate HSE controls to perform higher risk tasks at work;

• Will your planned activities today involve accessing Manholes?

  Yes

  No

• Accessing Manholes - If you plan on accessing manholes today. Please ensure you have available the following HSE items;

  Select Barriers - Full set to fully enclose Manhole Safety Cones x 2 for pedestrian management Gas Detector - confirming you know ho to use it Gas Detector is within calibration dates? Manhole Lid - Can fit inside your barriers or you have additional set Understand what is an SWL and know not to access them?

  • Barriers - Full set to fully enclose Manhole
  • Safety Cones x 2 for pedestrian management
  • Gas Detector - confirming you know ho to use it
  • Gas Detector is within calibration dates?
  • Manhole Lid - Can fit inside your barriers or you have additional set
  • Understand what is an SWL and know not to access them?

• SWL - An SWL is a Telstra - Special Work Location - These include Manholes over 2m Deep. To access a SWL Manhole - You must have harness and recovery system. Please confirm you understand this and agree not to fully enter an SWL as part of your work today. If you need to access - You must seek permission from your manager.

  Yes

  No

• Will your planned activities today involve using a Ladder?

  Yes

  No

• Please ensure you understand the list below by agreeing to the items in checklist.

  Select You have received training on Safe Work on Ladders You understand you cannot work on a ladder above 2 meters from ground You cannot access a ladder where secondary fall is greater than 2 meters

  • You have received training on Safe Work on Ladders
  • You understand you cannot work on a ladder above 2 meters from ground
  • You cannot access a ladder where secondary fall is greater than 2 meters

VEHICLE CHECKLIST

• Will you be using a self driven vehicle - you own or companies - to access field based activities today?

  Yes

  No

• Vehicle Checklist - All self driven vehicle types.

  Select Confirm the vehicle you are using is currently register for use on public roads Confirm the vehicle you are using is roadworthy for task - Confident that the equipment load you are transporting is stable and will not harm you or passengers when you stop, accelerate or turn. Fire Extinguisher with hose in vehicle You are not under influence of drugs, medicines or alchohol You are well rested and safe to drive

  • Confirm the vehicle you are using is currently register for use on public roads
  • Confirm the vehicle you are using is roadworthy for task -
  • Confident that the equipment load you are transporting is stable and will not harm you or passengers when you stop, accelerate or turn.
  • Fire Extinguisher with hose in vehicle
  • You are not under influence of drugs, medicines or alchohol
  • You are well rested and safe to drive

• Have a great day at work. Please use below text box if you have feedback regarding this form or would like to add something to CIS International HSE Best Practise - Please note if you do add something, be sure to send a PDF to your manager alerting them to this entry.