Title Page

  • Street Name/Location
  • RCA Permit Reference

  • Attended/Unattended

  • Principal

  • Employer of Site STMS

  • Delegation Scanner

  • WCC Auditor

  • WCC Auditor Number

  • Date/Time

Responsible Party

  • STMS/TC Attended at Site?

  • Name

  • Registration Number:

  • Action Needed


  • On Site?

  • Appropriate To Situation?

  • TMD Reference Number

  • Action Needed

High-Visibility Garments

  • Worn By All?

  • Done Up?

  • Condition Acceptable?

  • Action Needed


  • All Necessary Signs Present?

  • Correct Positions?

  • Sand Bagged For Expected Wind?

  • Conflicting Signs Covered?

  • Signs In Good Condition?

  • Other:

  • Action Needed


  • Protects Working Space/Other Features?

  • Longitudinal Safety Zone Appropriate?

  • Lateral Safety Zone Appropriate?

  • Taper Lengths Compliant?

  • Correct Spacing Of Cones?

  • Sufficient Positive Traffic Control?

  • Other:

  • Action Needed

Pedestrian Needs

  • Footpath Widths Ok?

  • Safe Passage For Pedestrians?

  • Surfaces/Ramps OK?

  • Other:

  • Action Needed

Cyclist Needs

  • Cycle Widths Ok?

  • Safe Passage For Cyclists?

  • Surfaces OK?

  • Other:

  • Action Needed

Traffic Needs

  • Lane Widths Ok?

  • Speed Limit Appropriate?

  • No Significant Delays?

  • Surfaces OK?

  • Other:

  • Action Needed

Property Access

  • Property Access OK?

  • Action Needed

Action Agreed By STMS/TC

  • Pictures Of Site

  • Actions Agreed

  • WCC Auditor Signature

  • STMS/TC Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.