Take 5

• Task

• Location

  Select

• Conducted by

• Conducted on

  Date

Stop and Think Through the Task

• Are you fit for work

  Yes

  No

  N/A

• 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

• Do I have approved documentation for the task?

  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 to do the task

  Yes

  No

  N/A

Identify and Assess the Hazards

• Provide corrective actions for hazards identified by clicking on 'Action' on the items below. Describe the action to take, assign a member, set priority level and due date.

Hazard

• Describe the hazard

• Control measure

Control and Monitor

• Are all hazards identified controlled or removed?

  Yes

  No

Completion

• Name & Signature of Assigned Employee

  Sign