WANNON WATER CAPITAL WORKS SITE INSPECTION FORM

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Date and Time of Inspection

  Date

Contract Information

• Contract Number

• Contractor

• Contractor Site Supervisor

• Plant on site

• Site/Weather conditions

• Tasks being performed

• No. of personnel

Potential HAZARDS on Site - (At least all hazards listed below should be considered).

• 1. Airborne contaminants (gases, dust, sparks, fumes - ventilation, safety eyewear.)

  Safe

  At Risk

  N/A

• 2. Biological hazards (people, flora & fauna).

  Safe

  At Risk

  N/A

• 3. Chemicals ( MSDS, workers instructed, PPE, storage containment)

  Safe

  At Risk

  N/A

• 4. Dangerous goods ( flammables, prescribed wastes, corrosives - storage, handling)

  Safe

  At Risk

  N/A

• 5. Electricity ( ELCBs, elevated from damage and water - tested and tagged - RGBY)

  Safe

  At Risk

  N/A

• 6. Gravity ( fall prevention - from height, same level, down shafts)

  Safe

  At Risk

  N/A

• 7. Mechanical ( Pre- start checklist, leaks/spills, guarding , etc. )

  Safe

  At Risk

  N/A

• 8. Microbiological ( contact with bacteria - skin, breathing protection)

  Safe

  At Risk

  N/A

• 9.Musculoskeletal ( push, pull, hold, restrain, lift, lower- systems, mech. Assistance )<br>

  Safe

  At Risk

  N/A

• 10. Noise ( plant or process - prefer block at source or pathway, then receiver)

  Safe

  At Risk

  N/A

• 11. Pressure ( hydraulics, pneumatics, springs, leaks/spills).

  Safe

  At Risk

  N/A

• 12. Psychosocial ( harassment, bullying , co-operation, compliance)

  Safe

  At Risk

  N/A

• 13. Radiation ( UV, welding, X- rays - protection for workers and passers-by )

  Safe

  At Risk

  N/A

• 14. Thermal ( excess heat, cold, Fire Fighting Equipment available and maintained)

  Safe

  At Risk

  N/A

• 15. Vibration ( whole or part body )

  Safe

  At Risk

  N/A

• 16. Water Quality ( sediment, discharge, groundwater )

  Yes

  No

  N/A

• 17. Cultural heritage ( EMP, induction, etc ).

  Yes

  No

  N/A

COMMENTS

EMERGENCY PROCEDURES IN PLACE

• Confined space

  Yes

  No

  N/A

• Working at height

  Yes

  No

  N/A

• Chemical spill

  Yes

  No

  N/A

• Overhead or underground power

  Yes

  No

  N/A

• Fire / Explosion

  Yes

  No

  N/A

• First Aid Facilities Assessment done

  Yes

  No

  N/A

INDUCTION

• Have all workers been inducted to site (if not why not?)

  Yes

  No

  N/A

• Have all workers been inducted to their JSA ( if not why not ?)

  Yes

  No

  N/A

• Are relevant JSAs being followed

  Yes

  No

  N/A

PERMITS

• Any special permits required ( e.g. Confined space, hot work, near power or other services) If yes please list permit name and number.

  Yes

  No

  N/A

• If yes, are permit requirements being complied with? ( note permit number )

  Yes

  No

  N/A

OTHER

• Any written confirmations issued? If yes list numbers below.

  Yes

  No

  N/A

• Any infringements issued? If yes list numbers below.

  Yes

  No

  N/A

• Wannon Water Officer name :

• Wannon Water Officer signature:

  Sign

TRIM Information

• Date Registered

  Date

• Folder Number

• Trim Number