Title Page
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Fault reference:
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Location:
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Description
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Select date
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1. Access arrangements to site:
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2. Area in which work to be carried out
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3. Is work to be carried out at height? (Type of scaffold or access equipment to be used in notes)
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4. Does the work involve digging or excavation?
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5. Is a permit to work required?
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Permit to excavate
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Hot works permit
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Ladder/Stepladder permit
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Electrical Systems Permit
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Entry permit
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Permit to demolish
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6. COSHH - Substances to be used
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COSHH Assessment number:
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Ensure COSHH Assessment is on site and operatives briefed
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7. Does the work equipment expose operatives to excessive noise levels and vibration?
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Tool 1
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Tool description
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Vibration level (m/s2)
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Time to EAV (Exposure action Value)
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Noise Level dB(A)
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Tool 2
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Tool description
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Vibration level (m/s2)
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Time to EAV (Exposure action Value)
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Noise level dB (A)
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Tool 3
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Tool description
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Vibration level (m/s2)
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Time to EAV (Exposure action Value)
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Noise level dB(A)
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Refer to Tool Selector Guides or information tag/sticker on plant.
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8. Will the works require Manual Handling? (If YES complete Manual Handling Assessment)
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9. Type of plant to be used
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Ensure Plant operators hold valid and current competancy
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10. What are the risks to the environment?
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11. Waste disposal - specify types of waste to be disposed of:
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Controlled Waste
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Hazardous Waste
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12. Well fare facilities are available at
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Hazard Risk Controls
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Hazard
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Risk
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Control
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Hazard
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Risk
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Control
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Hazard
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Risk
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Control
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Hazard
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Risk
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Control
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Control Measures - Operational
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- Not applicable
- T3 Possession
- Electrical Isolation
- Lookout warning
- Safeguarded
- Fenced
- Site Warden warning
- Line Blockage
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Line Blockage +
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Control Measures - PPE
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Specify other
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Confirmation of Briefing
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Add signature
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Select date
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Add signature
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Add signature
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Select date
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Add signature
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Completed by:
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Add signature
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Review Date
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Comments
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Reviewed by
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Review Date
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Comments
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Reviewed by
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