WORKSITE SAFETY PLAN

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Job specific

• Job no

• Description of Job/Task

• Emergency telephone numbers and location of assembly points

Hazard Prompts

• Minimum approach required

  No

  maintain appropriate MAD at all times

• Any electrical shock danger, including adjacent live equipment.

  Safe

  At Risk

  N/A

• Can tripping or LOS result from task.

  Safe

  At Risk

  N/A

• Are there any underground hazards

  Safe

  At Risk

  N/A

• Any other contractors working on site

  No

  Ensure good communication at all times.

• Are you working above 2 meters

  Wear and use correctly all relevant safety equipment

  No

• Is the pole or structure safe to climb

  Yes

  No

  N/A

• Any confined space hazards

  Safe

  At Risk

  N/A

• Any hazardous substances being used

  Safe

  At Risk

  N/A

• Any flammable vapor or toxicity <br>from product or process

  Safe

  At Risk

  N/A

• Any contamination to soil or water likely

  Safe

  At Risk

  N/A

• Is there any danger from machinery

  Safe

  At Risk

  N/A

• Is there any grinding/ welding / hot work

  Safe

  At Risk

  N/A

• Is there any danger from noise exposure

  Safe

  At Risk

  N/A

• Any heavy lifting to take place

  Safe

  At Risk

  N/A

Any other significant hazards

• Identified Hazard

• Rating

  1

  2

  3

  4

• Eliminate,Isolate,Minimise

  Eliminate

  Isolate

  Minimise

• Control measures

• Identified Hazard

• Rating

  1

  2

  3

  4

• Eliminate,Isolate,Minimise

  Eliminate

  Isolate

  Minimise

• Control measures

Control Prompts

• Is the Test equipment calibration current

  Yes

  No

  N/A

• PPE issued applicable to hazards

  Yes

  No

  N/A

• Is portable electrical equipment in date

  Yes

  No

  N/A

• Are MSDS avalible

  Yes

  No

  N/A

• Are the equipment ID / labels clear

  Yes

  No

  N/A

• Appropriate tools & Equipment available fro job

  Yes

  No

  N/A

Legislative Prompts

• Regulatory procedures available (eg TP specs ,SM-EI )

  Yes

  No

  N/A

Work procedures have been read and understood by all work party members

• Total work party to sign as acknowledgement of their understanding of contents and implications of this form

• Team member

  Sign

• Team member

  Sign

• Team member

  Sign

• Team member

  Sign

• Team member

  Sign

• Team leader to acknowledge that all team members understand the contents and implications of this from

• Team leader

  Sign