Task Number:



Customer Name:
Delivery Address:
Site Address:
Check the site for hazards before starting work. If any hazards are identified that are not assessed in SWMS, develop new controls and consult with workers or others who may be impacted.
Q1. Do you have a Safe Work Procedure (SWI/SWMS) for the works you do?
 Yes    No    If “No”, Contact WHS Manager and obtain and review safe work instruction
Q2. Are all of your electrical equipment and leads tested, tagged and safe to use?
 Yes    No    If “No”, Do not use unsafe equipment
Q3. Does Scaffolding have scaff tag and scaffolding has not been altered (e.g. removed -floor plates, rails, joists etc.)
 Yes    No      NA     If “No”, Do not use the scaffolding. Contact the site building manager
Q4. Fall zones and penetrations are protected? (e.g. stair voids, balconies etc.)
 Yes    No      NA     If “No”, If “No” If hazard cannot be controlled contact the site building manager
Q5. Are you working Alone?
 Yes    No    If “Yes”, Ensure to activate the “Mobile Alarm”
Q6. Are there other hazards identified?
Hints on Hazards to look for:
Slip, trip falls, overhead powerlines, plant operating in work areas, open pits, unprotected edges, chemicals exposure, Impaling (pickets, reo- bars, nails), falling objects etc.
 Yes    No    If “Yes”, identify the additional controls. You may escalate to manager if unsure of hazard management. Write down additional controls in below text box.”
No. Hazard Controls Implemented
1
2
3
Filled by:
Date: