Take 5

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• FOCUS ON .... Eyes on Hands, Eyes on path and line of fire

STOP and think through the job

• Are you fit to perform the required task

  Yes

  No

  N/A

• Do you understand the job

  Yes

  No

  N/A

• Are you competent to do the work and familiar with the equipment

  Yes

  No

  N/A

• Are the tools and equipment in a safe condition

  Yes

  No

  N/A

• Do you have an SWI and JHA for the task

  Yes

  No

  N/A

• Have you informed others that may be affected by your work

  Yes

  No

  N/A

ASSESS THE WORK. Dose the job involve any of the following?

• Equipment isolation

  Safe

  At Risk

  N/A

• Confined space work

  Safe

  At Risk

  N/A

• Working at heights

  Safe

  At Risk

  N/A

• Use of cranes or other lifting devices

  Safe

  At Risk

  N/A

• Use of mobile equipment

  Safe

  At Risk

  N/A

• Hot work

  Safe

  At Risk

  N/A

• Assistance from others

  Yes

  No

  N/A

• Use of barricades

  Yes

  No

  N/A

• Communication in noisy areas

  Safe

  At Risk

  N/A

• Potential environmental impacts

  Safe

  At Risk

  N/A

SEE THE HAZARDS- Look to identify any potential hazards

• Gravity

  Safe

  At Risk

  N/A

• Vehicles

  Safe

  At Risk

  N/A

• Human

  Safe

  At Risk

  N/A

• Electrical

  Safe

  At Risk

  N/A

• Mechanical

  Safe

  At Risk

  N/A

• Vibration

  Safe

  At Risk

  N/A

• Hazardous atmosphere

  Safe

  At Risk

  N/A

• Chemicals

  Safe

  At Risk

  N/A

• Thermal

  Safe

  At Risk

  N/A

• Pressurized system

  Safe

  At Risk

  N/A

• Radiation

  Safe

  At Risk

  N/A

• Flying objects

  Safe

  At Risk

  N/A

• Trip Hazards

  Safe

  At Risk

  N/A

• Manual handling

  Safe

  At Risk

  N/A

• Caught in- rotating or moving equipment

  Safe

  At Risk

  N/A

• Noise

  Safe

  At Risk

  N/A

• Engulfment

  Safe

  At Risk

  N/A

• Sunlight

  Safe

  At Risk

  N/A

• Fibres

  Safe

  At Risk

  N/A

• Cold surfaces

  Safe

  At Risk

  N/A

• Gases

  Safe

  At Risk

  N/A

• Dust

  Safe

  At Risk

  N/A

• Other

  Safe

  At Risk

  N/A

• Name of auditor

  Sign