USS Take 5

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

1. STOP and THINK before you start

2. What is my task

• Do I understand the job task I am performing?

  Yes

  No

  N/A

• Am I using/ have the right equipment?

  Yes

  No

  N/A

• Have I done this task before?

  Yes

  No

  N/A

• Am I working alone

  Yes

  No

  N/A

3. What are the HAZARDS?

• Do I know what can cause me and others harm?

  Safe

  At Risk

  N/A

• Have I informed the site manager of the hazards I will be introducing to this site

  Yes

  No

  N/A

• Are the hazards I introduce to the site identified to the site?

  Safe

  At Risk

  N/A

• Can I detect new hazards?

  Safe

  At Risk

  N/A

• Am I prepared if conditions change?

  Safe

  At Risk

  N/A

4. How can I protect myself?

• Is this the safest way to do the task?

  Yes

  No

  N/A

• Am I working in a safe location?

  Yes

  No

  N/A

• Is exposure to hazards minimal?

  Yes

  No

  N/A

• Am I wearing the correct PPE?

  Yes

  No

  N/A

5. What if things go wrong?

• Can I get to a safe place if needed?

  Yes

  No

  N/A

• Can I stop the task safely?

  Yes

  No

  N/A

• Can I raise the alarm and warn others?

  Yes

  No

  N/A

• Will anyone know where I am?

  Yes

  No

  N/A