TAKE 5

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

TAKE 5

• Name

• Time and Date

  Date

• Job Location

• Job Description

• STOP , THINK AND IDENTIFY THE TASK - MANAGE THE RISK

• Am I fit to carry out the task?

  YES

  NO

• CONTROLS

• Do I fully understand the task?

  YES

  NO

• CONTROLS

• Do I have the correct tools for the task?

  YES

  NO

• CONTROLS

• Is there a procedure or JSEA for the task and have you read and understood it?

  YES

  NO

• CONTROLS

• Am I trained and competent to carry out the task?

  YES

  NO

• CONTROLS

• Do you have the correct PPE for the task?

  YES

  NO

• CONTROLS

• Is my work area safe?

  YES

  NO

• CONTROLS

• Can I get caught in or between anything?

  NO

  YES

• CONTROLS

• Can my work affect anyone else's safety? Eg interaction

  NO

  YES

• CONTROLS

• Have I I identified all dangerous energy sources?

  YES

  NO

• CONTROLS

• Is there exposure to excessive heat/dust/noise/vibration?

  NO

  YES

• CONTROLS

• Can anything fall on me?

  NO

  YES

• CONTROLS

• Is a permit required

  NO

  YES

• CONTROLS

• Can My actions harm the environment?

  NO

  YES

• CONTROLS

• Other

  NO

  YES

• List

• CONTROLS

• Have all hazards been considered and controls been put in place

  YES

  NO

• DO NOT PROCEED CONTACT YOUR SUPERVISOR

• Signature(s)

Person

• Add signature

  Sign