take 5

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• THE HAZARADS IDENTIFIED ARE TO BE MANAGED BY PRE-DEFINED "HAZARD CONTROL SHEETS" (HCS), JOB SAFETY ANALYSIS (JSA), SAFE WORK METHOD STATEMENTS (SWMS), STANDARD OPERATING PROCEDURES (SOP), PERMIT TO WORK (PTW) OR A COMBINATION OF THESE.

PREPARATION

• Job No - enter job number

• Type of service provided:

  Planned Maintenance

  Repair

  System Down

  Update

  NA

DECLARATION

• Do you have the correct tools for the required task

  Yes

  No

  N/A

• Is your test equipment within calibration dates

  Yes

  No

  N/A

• Have you got the correct PPE

  Yes

  No

  N/A

• Have you got the correct documentation

  Yes

  No

  N/A

WORK ENVIRONMENT

• Work area Safe

  Safe

  At Risk

  N/A

• Access restricted or blocked to non Siemens staff

  Yes

  No

  N/A

• Biohazard

  Isolated

  Removed

  NA

• Manual handling hazard

  Correct lifting methods

  Seeking assistance

  NA

• Trip / Slip Hazard

  Isolated

  Removed

  NA

TASK

• CB Docs available and up to date

  Yes

  No

  N/A

• Room secured for X-Ray testing

  Room secured

  Not secured

  NA

• Electrical Isolation performed

  Yes

  No

  N/A

• Pre-Start Safety Checks completed and safe to proceed

  Yes

  No

  N/A

• Take photos of items, issue, equipment, hazard (Optional)

  Media

• Edit drawings

  Drawing

• Name and Signature

  Sign

• Enter time of this Prestart

  Date