VicRoads Take 5

• Document No.

• Job Location

• Job Description

• Conducted on

  Date

• Prepared by

• Location
  Address

• Weater Conditions: eg Sunny, Windy, Dry

  Select Very Cold Cold Warm Hot Very Hot Still Breeze Moderate Wind Strong Wind Very Strong Wind Dangerous Wind Fog / Mist Spitting Rain Showers Moderate Rain Rain Heavy Rain Hail Large Hail Snow Sunny Partly Cloudy Overcast Low Cloud Dry Slippery Flooding Smoke

  • Very Cold
  • Cold
  • Warm
  • Hot
  • Very Hot
  • Still
  • Breeze
  • Moderate Wind
  • Strong Wind
  • Very Strong Wind
  • Dangerous Wind
  • Fog / Mist
  • Spitting Rain
  • Showers
  • Moderate Rain
  • Rain
  • Heavy Rain
  • Hail
  • Large Hail
  • Snow
  • Sunny
  • Partly Cloudy
  • Overcast
  • Low Cloud
  • Dry
  • Slippery
  • Flooding
  • Smoke

• Personnel

• Site Photo:

  Media

1. STOP! LOOK AROUND THE WORKSITE

• Observe the work area and surrounds for hazards. Look Close, Look Above, Look Below, Look Wide and Look for Hidden Hazards

2. STOP! THINK THROUGH THE TASK

• 1. Are we clear on what the task is?

  Yes

  No

• STOP! Talk to your supervisor

• 2. Have we checked the SWMS/WIs for the task?

  Yes

  No

• STOP! Talk to your supervisor

• 3. Do we have the required skills, training, licences and permits for the task?

  Yes

  No

• STOP! Talk to your supervisor

• 4. Is all the equipment and tools suitable to the task and in good order? Are all electrical tools tagged and tested?

  Yes

  No

• STOP! Talk to your supervisor

• 5. Do we have all the appropriate PPE?

  Yes

  No

• STOP! Talk to your supervisor

• 6. Is the plant suitable for this task?

  Yes

  No

• STOP! Talk to your supervisor

• 7. Do we have an agreed form of communication for the task?

  Yes

  No

• STOP! Talk to your supervisor

• 8. Does the TMP suit the site? Do we have an MOA?

  Yes

  No

• STOP! Talk to your supervisor

• 9. Do we have a clear plan & job steps in mind?

  Yes

  No

• STOP! Talk to your supervisor

Photo's & Document's

• Add media

  Media

3. LOOK FOR HAZARDS, ASSESS THE HAZARDS

• A. Are there vehicles or plant reversing?

  Yes

  No

  N/A

• STOP! Talk to your supervisor, Detail control measures above.

• B. Is there a risk of plant rollover? Uneven/sloping ground conditions?

  Yes

  No

  N/A

• STOP! Talk to your supervisor, Detail control measures above.

• C. Are there overhead services?

  Yes

  No

  N/A

• STOP! Talk to your supervisor, Detail control measures above.

• D. Are there underground services?

  Yes

  No

  N/A

• STOP! Talk to your supervisor, Detail control measures above.

• F. Could I fall?

  Yes

  No

  N/A

• STOP! Talk to your supervisor, Detail control measures above.

• E. Do you need Dial Before you Dig?

  Yes

  No

  N/A

• STOP! Talk to your supervisor, Detail control measures above.

• H. Could something fall on me or strike me?

  Yes

  No

  N/A

• STOP! Talk to your supervisor, Detail control measures above.

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

  Yes

  No

  N/A

• STOP! Talk to your supervisor, Detail control measures above.

• I. Will the task take longer than 20 minutes and/or is the sight distance less than 250m?

  Yes

  No

  N/A

• STOP! Talk to your supervisor, Detail control measures above.

• J. Do I need to Work Alone?

  Yes

  No

  N/A

• STOP! Talk to your supervisor, Detail control measures above.

• L. Could I strain or over exert myself?

  Yes

  No

  N/A

• STOP! Talk to your supervisor, Detail control measures above.

• K. Could I slip or trip?

  Yes

  No

  N/A

• STOP! Talk to your supervisor, Detail control measures above.

• N. Are there any other hazards not identified – Environmental, Biological, Chemical, Electrical, Atmospheric, Fire/Explosions, Gravitational, Manual Handling, Mechanical, Pressure

  Yes

  No

  N/A

• STOP! Talk to your supervisor Enter Details:

• M. Could I come in contact with something that may harm me or others like chemicals, heat, gas, fumes, or pressurised pipes?

  Yes

  No

  N/A

• STOP! Talk to your supervisor, Detail control measures above.

Photo's & Document's

• Add media

  Media

4. COMMUNICATE AND CONTROL HAZARDS

• i. Have I communicated to my workmates the risks associated with this task and the controls implemented?

  Yes

  No

• ii. Have I controlled all the hazards so I will be safe?

  Yes

  No

• STOP! Talk to your supervisor, enter control measures above.

• iii. Does this feel right?

  Yes

  No

• STOP! Talk to your supervisor

5. DO THE JOB SAFELY Note: If the job changes whilst you are doing it, STOP and re-do the Take 5 steps to make sure you are safe

• Hazards Identified

• Controls Implemented

• Notes

• Sketch

  Drawing

• Photos & Documents:

  Media

• Employee Sign Off

  Sign

• 
  
  Supervisor Review / Sign Off _________________________________________ Date ____________________________