Take 5 Safety Checklist

• Conducted on

  Date

• Prepared by

  Select Chris Jackson Hugh Mavin Matt Zemek

  • Chris Jackson
  • Hugh Mavin
  • Matt Zemek
• Location
  Address

• Have you received induction training?

  Yes

  No

• Can the task cause injury or damage if conducted incorrectly?

  Yes

  No

• If YES, is there a procedure/JSEA/SWMS for this task?

  Yes

  No

• Do you know the company’s health & safety rules?

  Yes

  No

• Do I have a clear plan to complete the task safely?

  Yes

  No

• Are you familiar with how to report hazards & incidents?

  Yes

  No

• Is a Work Permit required e.g high risk work

  Yes

  No

• Are there emergency facilities and an evacuation procedure/route for the site?

  Yes

  No

• Do you have access to appropriate emergency and first aid equipment?

  Yes

  No

• Have you asked the person in charge about all relevant hazards?

  Yes

  No

• Do you have the correct procedures and equipment to do the work safely?

  Yes

  No

• Is there appropriate separation of vehicles and people during the proposed work?

  Yes

  No

• Is all required electrical/mechanical equipment in a safe condition?

  Yes

  No

• Are hazardous/dangerous substances used and stored according to their safety data sheets?

  Yes

  No

• Have you consulted with workers about the task and the safe way to do it?

  Yes

  No

• Do you have all necessary PPE?

  Yes

  No

• Have you got a safe way of getting in and out of your work area?

  Yes

  No

• Have any manual handling risks been identified and accessed?

  Yes

  No

• Have I identified all STORED energies?

  Yes

  No

Identifying the Hazards

• Do I have to isolate to control an energy source?

  Yes

  No

• Am I fit to perform this task (aware, rested, alert)?

  Yes

  No

• Could weather/environmental conditions affect this task?

  Yes

  No

• Could this task introduce new hazards

  Yes

  No

• Could this task impact on the environment?

  Yes

  No

• Is the work area neat and tidy (clear access)?

  Yes

  No

• Can I slip, trip or fall?

  Yes

  No

• Can I strain or over-exert myself?

  Yes

  No

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

  Yes

  No

• Can something fall on/strike me or others?

  Yes

  No

• Have I looked close/wide/above/below the area for hazards?

  Yes

  No

• Do I need assistance/help to do this task?

  Yes

  No

• Are there other hazards to consider before commencing?

  Yes

  No

Assess the Risk

• Description of Hazard:

Manage the Hazard

• Controls Implemented to Reduce Risk

Risk Rating

• Low

  Medium

  High

  Extreme

Proceed and Monitor

• Have all hazards been rated LOW/Medium? If 'No', inform your SUPERVISOR immediately

  Yes

  No

Signature

• Add signature

  Sign