Work Verification Record - FORM 102 - local copy

• Document No.

• Road / Segment / Lot

• Prepared by

• Business Unit

• Conducted on

  Date
• Location
  Address

• Team

• For information about this form see procedure: OCP-18

• For all findings of Not acceptable, complete a nonconformance report (NCR).

1 - Quality Requirements

• 1.1- Is a Project Specific Plan or Plan for Minor Works available on site?

  Acceptable

  Not Acceptable

  Not Applicable

  Not Checked

• 1.2- Is rework being documented?

  Acceptable

  Not Acceptable

  Not Applicable

  Not Checked

• 1.3- Are nonconformances correctly identified and documented?

  Acceptable

  Not Acceptable

  Not Applicable

  Not Checked

2 - Work procedure

• 2.1- Is the activity programmed on the works schedule?

  Acceptable

  Not Acceptable

  Not Applicable

  Not Checked

• 2.2- Is the correct procedure (MAP, Work Method Statement or Tech Procedure) in use?

  Acceptable

  Not Acceptable

  Not Applicable

  Not Checked

• 2.3- Do work methods comply with the procedure?

  Acceptable

  Not Acceptable

  Not Applicable

  Not Checked

• 2.4- Are requirements of Inspection/ Test Points being achieved?

  Acceptable

  Not Acceptable

  Not Applicable

  Not Checked

• 2.5- Are all sections of the Accomplishment Record (AR) being accurately completed?

  Acceptable

  Not Acceptable

  Not Applicable

  Not Checked

• 2.6- Are work quantities for routine services within + or - 10%?

  Acceptable

  Not Acceptable

  Not Applicable

  Not Checked

3 - WHS&R requirements

• 3.1- Was a risk assessment (Situational Awareness for Mtce) undertaken and documented?

  Acceptable

  Not Acceptable

  Not Applicable

  Not Checked

• 3.2- Have required site inductions been done correctly and recorded?

  Acceptable

  Not Acceptable

  Not Applicable

  Not Checked

• 3.3- Are SWMS available and implemented correctly? <br>(See Workplace WHS verification guide, item 7)<br>

  Acceptable

  Not Acceptable

  Not Applicable

  Not Checked

• 3.4- Are toolbox meetings being conducted and recorded?

  Acceptable

  Not Acceptable

  Not Applicable

  Not Checked

• 3.5- Are personnel wearing correct PPE as per the SWMS?

  Acceptable

  Not Acceptable

  Not Applicable

  Not Checked

• 3.6- Is ‘housekeeping’ on site acceptable?

  Acceptable

  Not Acceptable

  Not Applicable

  Not Checked

• 3.7- All hired plant inspected prior to use using Form-304?

  Acceptable

  Not Acceptable

  Not Applicable

  Not Checked

• 3.8- Are Daily Plant Inspection sheets completed?

  Acceptable

  Not Acceptable

  Not Applicable

  Not Checked

• 3.9A- Are all operators licensed or certified?

  Acceptable

  Not Acceptable

  Not Applicable

  Not Checked

• 3.9B- RMS Plant Safety Log Books are maintained and initialled by Supervisor?

  Acceptable

  Not Acceptable

  Not Applicable

  Not Checked

• 3.10- Are SDSs available?

  Acceptable

  Not Acceptable

  Not Applicable

  Not Checked

• 3.11- Is a First Aider and a stocked first aid kit available?

  Acceptable

  Not Acceptable

  Not Applicable

  Not Checked

• 3.12- Are weekly WHS and environmental inspections completed?

  Acceptable

  Not Acceptable

  Not Applicable

  Not Checked

• 3.13- Do contract delivery drivers have a copy of ‘CoR Self assessment and declaration’ (Form-115)?

  Acceptable

  Not Acceptable

  Not Applicable

  Not Checked

4 - Environmental requirements

• 4.1- Was a risk assessment done (routine mtce and ordered works) or a CEMP prepared?

  Acceptable

  Not Acceptable

  Not Applicable

  Not Checked

• 4.2- Are erosion and sedimentation controls in place and checked as required?

  Acceptable

  Not Acceptable

  Not Applicable

  Not Checked

• 4.3- Are all chemicals stored in a bunded area?

  Acceptable

  Not Acceptable

  Not Applicable

  Not Checked

• 4.4- Is a spill kit available?

  Acceptable

  Not Acceptable

  Not Applicable

  Not Checked

• 4.5- Are waste and spoil disposed of at approved sites, with disposal documented?

  Acceptable

  Not Acceptable

  Not Applicable

  Not Checked

5 - Traffic control

• 5.1- Are the TCP and VMP approved?

  Acceptable

  Not Acceptable

  Not Applicable

  Not Checked

• 5.2- Are the TCP and VMP appropriate for site conditions?

  Acceptable

  Not Acceptable

  Not Applicable

  Not Checked

• 5.3- Are the TCP and VMP implemented as per design?

  Acceptable

  Not Acceptable

  Not Applicable

  Not Checked

• 5.4- If required, is the DTR in place with records kept?

  Acceptable

  Not Acceptable

  Not Applicable

  Not Checked

• 5.5- Are traffic control inspections records being completed accurately?

  Acceptable

  Not Acceptable

  Not Applicable

  Not Checked

• 5.6- Is pedestrian access/egress addressed?

  Acceptable

  Not Acceptable

  Not Applicable

  Not Checked

• 5.7- Are monthly Traffic Control Safety Inspections being completed?

  Acceptable

  Not Acceptable

  Not Applicable

  Not Checked

• Verifiers's Name (Work Supervisor)

• Add signature

  Sign

• Select date

  Date

• Workplace WHS verification guide
  1. Housekeeping
  Look at the work area – accumulated rubbish, tools and equipment left lying around can become trip hazards. Storage areas in trucks etc should be clean and tidy with materials stored in racks, bins, etc and provide easy access for the placement and retrieval of equipment and materials.
  2. First Aid
  First aid kits are to be kept clean, tidy and fully stocked. Each team should have a person responsible for maintaining the kit. All RMS vehicles must carry a first aid kit.
  3. Hazardous substances
  Substances include pesticides, solvents, cleaning agents, paints, epoxy, fertilisers, cement etc. All substances are to be stored correctly with all containers labelled correctly. A Material Safety Data Sheet (MSDS) must be available for each hazardous substance in the workplace.
  4. Personal protective equipment
  Compliance with personal protective equipment (PPE) requirements is mandatory on all RMS sites. PPE requirements for all specialist activities should be addressed during the inspection.
  5. Electrical
  Check power outlets for overload or faulty switches etc. An earth leakage circuit breaker must be used for all electrical work. All electrical tools and power leads used in construction work are to be tested and tagged monthly.
  6. Equipment: machinery and tools
  Ensure that equipment is in good working order and that operators are trained and certified to operate it. Check that safety-warning signs are legible. Ensure that equipment is operated in accordance with documented requirements. Check that guards are in place and in good order.
  7. Safe work practices and site conditions
  Unsafe work practices are the main cause of accidents. For example: lifting heavy objects without the aid of lifting or mechanical devices; jumping down from trucks and plant; failure to wear the PPE; removing guards from machinery; operating unsafe equipment; and failure to follow SWMS.
  Unsafe conditions are another cause of accidents. For example: exposure to extreme heat or cold; poor ventilation; worn or broken tools and equipment; congested or cramped working conditions; slippery or uneven surfaces; and work requiring repetitive movements.
  When considering unsafe conditions PPE should be your last resort. To control hazards the following approach should be taken: eliminate the hazard or use a substitute method, substance, etc in the work process or isolate the person from the hazard or minimise (reduce or lessen) the hazard.
  Note: Attach a marked up copy of the activity SWMS and subcontractor or hired plant operator SWMS verified.
  8. Fire and emergency
  Extinguishers and hose reels must be serviced every 6 months. Emergency procedures should be developed and all persons on site inducted into their requirements. Check that flammables are not exposed to ignition sources. Ensure that there is no accumulation of rubbish or combustible materials such as oily rags.