Take 5

• Document No.

• Job Location

• Job Description

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

STOP - Do I fully understand the task

• Am I competent and authorised?

  Yes

  No

  NA

• Discuss task with your supervisor before proceeding.

  

• Have any task changes been considered?

  Yes

  No

  NA

• Discuss task with your supervisor before proceeding.

  

• Do I have the correct PPE, tools, pre start and equipment?

  Yes

  No

  NA

• Discuss task with your supervisor before proceeding.

  

• Do I require a permit for the job?

  No

  Yes

  NA

• Discuss task with your supervisor before proceeding.

  

THINK - What are the hazards?

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

  No

  Yes

  NA

• Can I manage the hazards?

  Yes

  No

  NA

• Discuss the task with your supervisor before proceeding

  

• Can something fall on or strike me?

  No

  Yes

  NA

• Can I manage the hazards?

  Yes

  No

  NA

• Discuss the task with your supervisor before proceeding

  

• Can I strain or over except myself?

  No

  Yes

  NA

• Can I manage the hazards?

  Yes

  No

  NA

• Discuss the task with your supervisor before proceeding

  

• Is any equipment in the task required to be positively isolated?

  No

  Yes

  NA

• Can I manage the hazards?

  Yes

  No

  NA

• Discuss the task with your supervisor before proceeding

  

• Are there any hidden hazards that may harm me - chemicals, gases, fumes, heat, electricity, stored energy, poor communications or ventilation?

  No

  Yes

  NA

• Can I manage the hazards?

  Yes

  No

  NA

• Discuss the task with your supervisor before proceeding

  

• Can I slip, trip or fall?

  No

  Yes

  NA

• Can I manage the hazards?

  Yes

  No

  NA

• Discuss the task with your supervisor before proceeding

  

• Is access or egress a problem?

  No

  Yes

  NA

• Can I manage the hazards?

  Yes

  No

  NA

• Discuss the task with your supervisor before proceeding

  

• Is additional lighting required?

  No

  Yes

  NA

• Can I manage the hazards?

  Yes

  No

  NA

• Discuss the task with your supervisor before proceeding

  

• Could there be an uncontrolled movement?

  No

  Yes

  NA

• Can I manage the hazards?

  Yes

  No

  NA

• Discuss the task with your supervisor before proceeding

  

• Can this task affect the safety of my workmates or harm the environment?

  No

  Yes

  NA

• Can I manage the hazards?

  Yes

  No

  NA

• Discuss the task with your supervisor before proceeding

  

• Do I need to barricade the work area?

  No

  Yes

  NA

• Can I manage the hazards?

  Yes

  No

  NA

• Discuss the task with your supervisor before proceeding

  

• Do I know where the nearest escape route, refuge chamber or muster point is?

  Yes

  No

  NA

• Can I manage the hazards?

  Yes

  No

  NA

• Discuss the task with your supervisor before proceeding

  

• I am safe to proceed with the task

  Sign