Title Page

  • Street Name/Location
  • CAR/WAP Number

  • Attended/Unattended

  • Principal

  • Other (Please insert Principal details)

  • Temporary Traffic Management Contractor

  • Other (please insert TTM company)

  • Date/Time

Responsible Party

  • STMS/TC at site?

  • Name

  • Registration number:

  • Action needed


  • Acceptable/Unacceptable?

  • Missing signs (per sign)

  • Position (per sign)

  • Not visible/fallen over (per sign)

  • Wrong Sign (per sign)

  • Condition unacceptable

  • Permanent sign (per sign)

  • Unapproved sign used/too small (per sign)

  • Non-compliant support/sign too low (per support)

  • Action needed

  • Media


  • Acceptable/Unaaceptable

  • Tail pilot vehicle/AWVMS omitted or incorrect location (per vehicle)

  • Lead pilot vehicle omitted or incorrect location (per vehicle)

  • Shadow vehicle omitted or incorrect location (per vehicle)

  • TMA Missing or non compliant (per TMA)

  • AWVMS/arrowboard non compliant (per vehicle)

  • Action needed

  • Media


  • Acceptable/Unacceptable

  • Inadequate provision for pedestrians (per feature)

  • inadequate provision for cyclists (per feature)

  • Action needed

  • Media


  • Acceptable/Unacceptable

  • Missing or ineffective taper (leading taper)

  • Tapers too short (leading taper)

  • taper too short or missing (trailing taper)

  • spacing along lanes (per 100m)

  • Missing or ineffective delineation along lanes (per section)

  • Condition unacceptable (per device)

  • Using non-approved device (per device)

  • Inadequate/missing site access (access)

  • Action needed

  • Media


  • Working in live lanes (individual)

  • Missing or ineffective controller (individual)

  • Safety zone compromised (individual)

  • High visibility garment not acceptable (individual)

  • Marginal surface condition (carriageway only) - (Occasion)

  • Unacceptable surface condition (peds,cyclists or carriageway) - (Occasion)

  • Barrier defects (missing or incorrect components) - (Component)

  • Unsafe or redundant TTM (per equipment)

  • VMS message incorrect or inappropriate (per VMS)

  • Flashing beacons/indicator lights not used or ineffective (per vehicle)

  • Parking/stopping features not relocated (per feature)

  • Unsafe and illegal parking of plant/equipment (per feature)

  • Marginal items (signs, delineators, Hi vis garments) - (per feature)

  • Action needed

  • Media


  • Qualified person on site

  • TSL appropriate

  • Road user flow acceptable

  • On-site record (must include STMS authority 2 hourly checks and TSL details)

  • TMP approved

  • Approved TMP sighted

  • Approved TMP applicable

  • TTM in accordance with approved TMP

  • Action needed

  • Media

Key Points

  • Complaint Callout?

  • Site Activity Status

  • Audit/review

  • Notification to RCA (does not affect score)

  • Good site induction (does not affect score)

  • TMP Design issues?

  • Low Risk?


  • Actions to be taken

  • WCC ID

  • Auditor Signature

  • STMS Details


  • STMS 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.