V-F-12 JSEA (Mandatory)

• Site conducted

  Select

• Verdia Employee(s)

  Select

• Good

  Fair

  Poor

  N/A

undefined

• Good

  Fair

  Poor

  N/A

• As far as you are aware has you or anyone you plan to meet today travelled overseas in the past 14 days

  No

  Yes

• Do you, or, does anyone you plan to meet have flu like symptoms?

  No

  Yes

• As far as your aware has anyone you plan to meet been in contact with a person that has tested positive or is suspected of having COVID-19?

  No

  Yes

• If your answer to any of the questions above is "yes" select "At Risk" and do not proceed any further

  Safe

  At Risk

• Fill in "Client Name" and "Site Name" below only if you were unable to select your site name in "Where are you conducting this inspection". Help:
  https://verdia-my.sharepoint.com/:w:/g/personal/liwenyip_verdia_com_au/EV07emecW5tMjI7GPYLh_o0BOjxk06Osxk6aDk39hAw3Cg?e=iLL1D5

• Client Name

• Site Name

• Date / Time of Review

  Date
• Location
  Address

• Emergency Assembly Area:

• Photo of site before work commences

  Media

• If you need help with this form, call Li-Wen on 04 5555 7425
  
  Change log:
  10/12/2018: Made site name and client name fields optional
  01/08/2018:
  - Added multiple choice for "Verdia Employees" on first page - this is so that Andrew can see who has been signing on to other peoples' JSA
  - Split questions into separate pages
  - Added question "explain why SWMS is not required"
  - Added new questions that appear if you answer "yes" to Asbestos, work at heights, electrical hazards, confined spaces, site traffic; to check if you are doing anything that would be considered "high risk construction work"
  - Added dynamic fields to capture additional hazards and controls
  

DOCUMENTATION

• Has a Safe Work Method Statement been developed?

  Yes

  No

  N/A

• Why is a SWMS not required?

• Control measure

• All workers inducted into Safe Work Method Statement (SWMS)?

  Yes

  No

  N/A

• Control measure

• Weather conditions suitable - (heat, cold, rain)

  Yes

  No

  N/A

• Control measure

• Light sufficient for all tasks

  Yes

  No

  N/A

• Control measure

• Direct sunlight exposure

  No

  Yes

• Control measure

• Presence of potentially dangerous animals and fauna (including dogs, snakes and insects)

  No

  Yes

• Control measure

• Biological hazards (syringes, contaminated water)

  No

  Yes

• Control measure

• Use of hazardous substances and/or dangerous goods

  No

  Yes

• Control measure

• Ground surfaces, risk of trips and falls

  No

  Yes

• Control measure

• Asbestos (ACM) materials

  No

  Yes

• Control measure

• Are you doing anything that "(d) involves, or is likely to involve, the disturbance of asbestos"?

  No

  Yes

• Have you signed onto a SWMS that covers this specific task/hazard?<br>OR are you inspecting a site that is currently under the client's control, and are you under the client's supervision?

  Yes

  No

  N/A

• STOP - you must sign on to a SWMS before doing any "high risk construction work"

  

• Work at heights tasks

  No

  Yes

• Control measure

• Are you doing anything that "(a) involves a risk of a person falling more than 2 metres"?<br>(including accessing a roof with unprotected edges, or falling through a skylight or plastic roof sheeting)

  No

  Yes

• Is your name Paul McNally, Greg Kincaid, or Paul Candy

  Yes

  No

  N/A

• STOP - only Paul, Greg, or Paul C are allowed to work at heights where there is a risk of falling more than 2m

  

• STOP - you must sign on to a SWMS before doing any "high risk construction work"

  

• Have you signed onto a SWMS that covers this specific task/hazard?<br>OR are you inspecting a site that is currently under the client's control, and are you under the client's supervision?

  Yes

  No

  N/A

• STOP - you must sign on to a SWMS before doing any "high risk construction work"

  

• Electrical hazards

  No

  Yes

• Control measure

• Are you doing anything that "(k) is carried out on or near energised electrical installations or services"?

  No

  Yes

• Have you signed onto a SWMS that covers this specific task/hazard?<br>OR are you inspecting a site that is currently under the client's control, and are you under the client's supervision?

  Yes

  No

  N/A

• STOP - you must sign on to a SWMS before doing any "high risk construction work"

  

• Confined spaces

  No

  Yes

• Control measure

• Are you doing anything that "(f) is carried out in or near a confined space"?

  No

  Yes

• Have you signed onto a SWMS that covers this specific task/hazard?<br>OR are you inspecting a site that is currently under the client's control, and are you under the client's supervision?

  Yes

  No

  N/A

• STOP - you must sign on to a SWMS before doing any "high risk construction work"

  

• Site Traffic? (Trucks, Forklifts)

  No

  Yes

• Control measure

• Are you doing anything that "(n) is carried out on, in or adjacent to a road, railway, shipping lane or other traffic corridor that is in use by traffic other than pedestrians, or (o) is carried out in an area at a workplace in which there is any movement of powered mobile plant"?

  No

  Yes

• Have you signed onto a SWMS that covers this specific task/hazard?<br>OR are you inspecting a site that is currently under the client's control, and are you under the client's supervision?

  Yes

  No

  N/A

• STOP - you must sign on to a SWMS before doing any "high risk construction work"

  

• Are you doing any other "high risk construction work", i.e. work that<br>(b) is carried out on a telecommunication tower, or<br>(c) involves demolition of an element of a structure that is load-bearing or otherwise related to the physical integrity of the structure, or<br>(e) involves structural alterations or repairs that require temporary support to prevent collapse, or<br>(g) is carried out in or near:<br>(i) a shaft or trench with an excavated depth greater than 1.5 metres, or<br>(ii) a tunnel, or<br>(h) involves the use of explosives, or<br>(i) is carried out on or near pressurised gas distribution mains or piping, or<br>(j) is carried out on or near chemical, fuel or refrigerant lines, or<br>(l) is carried out in an area that may have a contaminated or flammable atmosphere, or<br>(m) involves tilt-up or precast concrete, or<br>(p) is carried out in an area in which there are artificial extremes of temperature, or<br>(q) is carried out in or near water or other liquid that involves a risk of drowning, or<br>(r) involves diving work.

  No

  Yes

• Have you signed onto a SWMS that covers this specific task/hazard?<br>OR are you inspecting a site that is currently under the client's control, and are you under the client's supervision?

  Yes

  No

  N/A

• STOP - you must sign on to a SWMS before doing any "high risk construction work"

  

• Are you doing anything involving awkward postures, lifting, lowering, pushing, pulling, or sudden body movement?

  No

  Yes

• Control measure

• Additional Hazards and Controls

Hazard

• Take a photo

  Media

• Description of Hazard

• Control measure(s)

Person

• Verdia

  Contractor

  Visitor

• Name

  Sign