Job Information

Complete the following form before starting work. Any further heath and safety requirements raised in this form must be addressed prior to commencing work.

Job Address: *

Street address *

Suburb *

City *

Postcode *

Job Description: *

Worker First Name: *

Worker Last Name: *

Company Name: *

Comments

Hazards and Controls

Noise - If YES, follow these controls: - Use hearing protection (earplugs or earmuffs) - Conduct regular noise level assessments - Limit exposure time to noisy environments - Use quieter machinery and tools where possible. *

YESNON/A

Dust - If YES, follow these controls: - Use dust suppression methods like water sprays or vacuums - Use appropriate respiratory protection (e.g., masks) - Ensure proper ventilation in work areas - Regularly clean work areas to minimise dust accumulation. *

YESNON/A

Public Safety - If YES, follow these controls: - Use fencing and signage to clearly define work areas - Have a site supervisor to monitor unauthorized access - Use barriers to separate work areas from public spaces - Induct visitors. *

YESNON/A

Electrical Equipment - If YES, follow these controls: - Ensure electrical equipment is regularly tested and tagged - Provide training on electrical safety - Use RCDs (Residual Current Devices) when possible - Inspect extension cords and power tools before use - Never use damaged equipment. *

YESNON/A

Power Tools - If YES, follow these controls: - Ensure all power tools are regularly inspected and maintained - Use appropriate PPE (e.g., gloves, goggles, ear protection) - Follow manufacturer’s instructions for each tool - Ensure guards are fitted properly. *

YESNON/A

Hazardous Substances - If YES, follow these controls: Use correct PPE (gloves, masks, etc.) - Ensure proper labelling and storage of chemicals - Keep working areas well ventilated - Refer to product SDS for further information. *

YESNON/A

Mould Infected Areas - If YES, follow these controls: Use appropriate PPE (masks, gloves) - Ensure proper ventilation in work areas - Remove and dispose of mould-infected materials according to guidelines - Use mould inhibitors where possible. *

YESNON/A

Ladders - If YES, follow these controls: - Inspect ladders before use - Ensure ladders are on stable, level ground - Use ladders of appropriate height and type for the task - Follow the three-point contact rule when climbing and descending. *

YESNON/A

Silica Dust - If YES, please complete a RISK ASSESSMENT before starting work. *

YESNON/A

Asbestos - If YES, please complete a RISK ASSESSMENT before starting work. *

YESNON/A

Working at Heights - Includes working on scaffolding, mobile elevated work platforms and roofs. If YES, please complete a RISK ASSESSMENT before starting work. *

YESNON/A

Restricted Space - If YES, please complete a RISK ASSESSMENT before starting work. *

YESNON/A

Live Cables or Power Lines - If YES, please complete a RISK ASSESSMENT before starting work. *

YESNON/A

Hot Work - If YES, please complete a HOT WORK PERMIT before starting work. *

YESNON/A

Structural Demolition - If YES, please complete a RISK ASSESSMENT before starting work. *

YESNON/A

Required PPE

List any other required PPE:

Emergency Procedure

In the case of emergency requiring evacuation of the site. Shut down all plant and equipment. All personnel on site are to proceed immediately by the safest route to the safe assembly point: THE FRONT OF PROPERTY BY LETTER BOX AWAY FROM OVERHEAD POWER LINES. And remain there, so all personnel can be accounted for. Do not return to site until it is safe to do so.

Dial 111 for: FIRE, AMBULANCE, POLICE, GAS, CHEMICAL SPILLS When calling 111, READ THE FOLLOWING TO THE DISPATCHER: We have an emergency at… We need help from Ambulance?/?Fire / Police… Directions to the emergency are… Our phone number is… The medical problem seems to be… Send someone outside to meet the emergency service.

Contact Details: WORKSAFE NZ (0800) 030 040 - POISON CENTRE (0800) 764 766 - SPILLS AND POLLUTION ECAN (0800) 765 588 - ANIMAL CONTROL CCC (03) 941 8999 - HEALTHLINE (0800) 358 5453

FIRST AID KIT AND FIRE EXTINGUISHER LOCATED IN VEHICLE OR SITE KIT (REQUIRED) *

YES

Signature

Please sign below to confirm you have reviewed and accept this job safety assessment. *

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Date: *