Take Five (Northmore Gordon)

• Client / Site

• Task

• Conducted on

  Date

• Prepared by

• Others who will be working with you on this task:

Think through the task

• Am I clear on what the task is?

  Yes

  No

• Do I have the required skills, qualifications and certificates for the task?

  Yes

  No

• If a Job Safety Analysis (Safe Work Method Statement) is needed, has one been completed?

  Yes

  No

  N/A

• Do I have a work permit / authority to work if one is needed?

  Yes

  No

  N/A

• Do I have the appropriate equipment for the task and are they in good working order?

  Yes

  No

  N/A

• Do I have the appropriate Personal Protective Equipment (PPE)?

  Yes

  No

  N/A

• If required, do all the team members have valid site induction? If there's an induction card, does everyone have their cards with them?

  Yes

  No

  N/A

Have you accounted for these hazards?

• Weather - high winds, hot/low temperatures, dust

• Biological - viruses, bacteria, inserts, spiders, birds, rats, other animals

• Chemical - acids, bases, vapours, solvents, heavy metals

• Electrical - earthing points, static charge, electrocution, faulty wiring/equipment, water

• Environment - loud noises, confined spaces, poor lighting, poor ventilation

• External - traffic, other workers, general public

• Fires & Explosions - open flames, combustible materials, chemical reactions

• Gravitational - falls, slips, trips, dropping objects, falling objects from above

• Manual Handling - lifting, pulling, pushing, twisting, awkward positions

• Mechanical - impacts, entanglements, stabbing, vibrations, crushing, suction, abrasions, protusions

• Pressure - high/low pressures, air, water, steam, gas, vacuum

• Radiation - sunlight, UV, nuclear, x-rays, lasers, infra-red

• Thermal - hot/cold surfaces, steam, friction, hot/cold liquids, hot/cold materials

Overview

• Have you minimized the risks or are they at an acceptable low level?

  Yes

  No

• Is another JSA / SWMS needed for this task?

  Yes

  No

• Are everyone on the team aware of the safety aspects for this task?

  Yes

  No

• Does this feel right?

  Yes

  No

• Will everyone on the team go home to their family safe and sound at the end of this task?

  Yes

  No

• Name & Signature (Note you're signing for everyone else on the team)

  Sign