HSA SMP 20 Forms all + blanks 12-5-10

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1.0

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Fo

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.1 –

Safe

Pass

Reg

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Ind

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No.

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D

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2.

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9.

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1.

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2

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3

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4

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5

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6

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7

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21

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1.

2.

3.

4.

5.

6.

7.

8.

9.

10

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11

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12

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16

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the to be erformed where re uired?

Sample Checklist for Site Induction

Purpose: To help familiarise employees with the health & safety rules and procedures before they start work on site.

No. Items Covered Yes No N/A

1. Have you established the competencies and qualifications e.g. Safe Pass FÁS CSCS

2. Have you briefed your employee on method statements / SSWP’s on work

3. Does the person have the correct PPE available?

• Hard hat

• Safety glasses

• Safety footwear

• High visibility clothing

• Ear protection

• Other……………………………………..

4. Have you shown the person what to do in an emergency and identified the location of the:

• Assembly point and evacuation route?

• Closest medical facility?

• Contact details of emergency services?

• Provisions for emergency communications?

5. Have you shown the person:

• The location of the first aid facilities / kits?

• Who the first aiders are and how to obtain treatment?

6. Have you shown the person where all relevant firefighting equipment is located? For example, fire extinguishers and hose reels

7. Have you introduced the person to their site Health and Safety Re resentative s where a licable?

8. Have you shown the person where the welfare facilities (including toilets and drinkin water are located?

9. Have you explained the procedures for reporting incidents, injuries and hazards?

10. Has the person been trained to set up and use any specialised e ui ment that is re uired?

11. Have you explained the site security procedures and site rules?

12. Have you given the person an opportunity to ask questions about their res onsibilities and to have an issues clarified?

Note: Where the person does not clearly understand English, use an interpreter to assist in translation

Form 1.4 - Induction Training

Pers

on

al

Pro

tect

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qu

ipm

en

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eg

iste

r N

am

e

Co

mp

an

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PPE R

ece

ived

D

ate

Sig

natu

re

Fo

rm 1

.6 –

Pers

on

al

Pro

tect

ive E

qu

ipm

en

t R

eg

iste

r

Page 1 of 2Health and Safety Authority: Form GA1

GA1 Report of Thorough Examination

NOTE:

This form may be used to record the thorough examination and testing of Lifting Equipment, as set out in the Safety, Health and Welfare at Work (General Application) Regulations, 2007. This form was produced by the HSA to facilitate the recording of information, as per Schedule 1 Part E of these regulations. This is not an approved or statutory form. Reports of Thorough examination may be produced in other formats.

Date: Reference:

Name and address of employer or owner for whom the thorough examination was made:

Address where thorough examination was made:

Particulars identifying the lifting equipment:

Date of manufacture:Serial Number:

Type of lifting equipment:

Safe Working Load Configuration(s)

Note: Each configuration should reflect the working arrangements, for example length of jib; fly jib; radius; angle; ballast; number of rope falls; height under hook. Please detail the safe working loads for all configurations, as per manufacturer's instructions. Use additional sheets if more than three configurations.

Testing Thorough Examination

Purpose of thorough examination and/or testing:

Particulars of tests carried out:

Latest date for next thorough examination:


Defect which is a danger to persons:

Repair, renewal or alteration required to remedy this defect:

Repair, renewal or alteration required to remedy this defect, including date(s):

Defect which could become a danger to persons:

Timeframe for defect becoming a danger:

Parts not accessible for examination:

Name, address and qualifications of person making the report: (print name in BLOCK CAPITALS)

Name and position of person authenticating the report: (print name in BLOCK CAPITALS)

Employer: Employer:

We certify that: (tick when done)

We have undertaken the test / thorough examination as prescribed

We have identified defects which are or could be a danger to persons

The particulars in this report of thorough examination are correct

You must: (tick to confirm you uderstand)

Keep this report of thorough examination safe and available for inspection

Undertake identified repairs

Arrange for a thorough examination or test before the latest date or as prescribed

Signed: Person performing tests or thorough examination

Signed: Person receiving report of thorough examination


GA2 Report of Weekly Examination

NOTE:

This form may be used to record the weekly examination of Lifting Equipment used on construction sites, as set out in the Safety, Health and Welfare at Work (General Application) Regulations, 2007. This form was produced by the HSA to facilitate the recording of the weekly examination as per these regulations. This is not an approved or statutory form. Reports of Weekly examination may be produced in other formats.

Name and address of contractor or owner for whom the weekly examination was made:

Address where weekly examination was made:

Description of lifting

appliance and means of

identification

Date of inspection

Result of inspection (state whether in good order, see note below)

Name of persons who made the inspection

(use BLOCK CAPITALS)

Note: Result of inspection should state if all working gear and anchoring or fixing plant or gear is in good working order. Including, where required the automatic safe load indicator and the derricking interlock.

Yes No Yes No

Component Inspected Good working order Action Required

Rated capacity indicator / limiter

Yes No Yes NoWire rope and chain systems

Yes No Yes NoLimit switches (e.g. hoist, derrick limit)

Yes No Yes NoRopes positioned on their sheaves

Yes No Yes NoStructure (major damage)

Yes No Yes NoHooks & other load lifting attachments

Yes No Yes NoHydraulic systems

Yes No Yes NoElectrical systems

Yes No Yes NoFuel lines

Yes No Yes NoBrakes and clutches

Yes No Yes NoOperator's cab

Yes No Yes NoOperator's controls

Yes No Yes NoAnemometer, where provided

Yes No Yes NoOther matters (manufacturer / user)

GA

3

- R

ep

ort

of

Resu

lts

of

Insp

ect

ion

s o

f:

W

ork

Eq

uip

men

t fo

r W

ork

at

a H

eig

ht

Nam

e of

per

son (

or

com

pan

y) f

or

whom

the

insp

ection w

as c

arried

out:

Addre

ss w

her

e in

spec

tion w

as c

arried

out

(site

or

oth

er w

ork

pla

ce):

Lo

cati

on

&

Desc

rip

tio

n o

f Eq

uip

men

t &

an

y

Iden

tifi

cati

on

N

um

bers

/ M

ark

s

Date

an

d

Tim

e o

f In

spect

ion

Resu

lts

of

Insp

ect

ion

*

incl

ud

ing

defe

cts

&

loca

tio

ns

Deta

ils

of

an

y c

orr

ect

ive

act

ion

s ta

ken

Deta

ils

of

an

y f

urt

her

act

ion

nece

ssary

Nam

e a

nd

p

osi

tio

n o

f p

ers

on

m

akin

g

insp

ect

ion

Sig

natu

re o

f p

ers

on

wh

o

mad

e

insp

ect

ion

* M

ust

sp

eci

fy d

eta

ils

of

an

y m

att

ers

id

en

tifi

ed

th

at

cou

ld g

ive r

ise t

o a

ris

k t

o t

he s

afe

ty o

r h

ealt

h o

f an

y

e

mp

loyee.

GA

3

- R

ep

ort

of

Resu

lts

of

Insp

ect

ion

s o

f:

W

ork

Eq

uip

men

t fo

r W

ork

at

a H

eig

ht

NO

TES

This

form

may

be

use

d t

o a

ssis

t in

com

plia

nce

with t

he

Saf

ety

Hea

lth a

nd W

elfa

re a

t W

ork

(G

ener

al A

pplic

atio

n)

Reg

ula

tions

2007

Reg

ula

tion 1

19 –

Insp

ection

of

Work

Equip

men

t in

rel

atio

n t

o s

caff

old

s, g

uar

d-r

ails

, to

e-boar

ds,

bar

rier

s or

sim

ilar

mea

ns

of

pro

tect

ion,

fixe

d a

nd m

obile

work

ing p

latf

orm

s, n

ets,

airbag

s

or

oth

er c

olle

ctiv

e sa

feguar

ds

for

arre

stin

g f

alls

, per

sonal

fal

l pro

tect

ion s

yste

ms,

work

posi

tionin

g s

yste

ms,

rope

acce

ss a

nd

posi

tionin

g t

echniq

ues

, fa

ll

arre

st s

yste

ms,

work

res

trai

nt

syst

ems

and lad

der

s. T

his

is

not

an a

ppro

ved o

r st

atuto

ry f

orm

. Rep

ort

s of

Insp

ection m

ay b

e pro

duce

d in o

ther

form

ats.

This

fo

rm d

oes

not

subst

itute

for

report

s of

thoro

ugh e

xam

inat

ion o

f lif

ting e

quip

men

t th

at m

ay b

e re

quired

under

oth

er s

tatu

tory

pro

visi

ons

(see

GA1 a

nd G

A2).

Safe

ty,

Healt

h a

nd

Welf

are

at

Wo

rk (

Gen

era

l A

pp

lica

tio

n)

Reg

ula

tio

ns,

20

07

- P

art

4 -

Reg

ula

tio

n 1

19

11

9.

(1

) An e

mplo

yer

shal

l en

sure

that

, as

reg

ards

work

equip

men

t to

whic

h R

egula

tions

101 t

o 1

14 a

pply

—

(a)

w

her

e th

e sa

fety

of

the

work

equip

men

t dep

ends

on h

ow

it

is inst

alle

d o

r as

sem

ble

d,

it is

not

use

d a

fter

inst

alla

tion o

r as

sem

bly

in a

ny

posi

tion u

nle

ss it

has

bee

n insp

ecte

d in t

hat

posi

tion,

(b

)

without

pre

judic

e to

par

agra

phs

(a)

and (

c),

work

equip

men

t ex

pose

d t

o c

onditio

ns

causi

ng d

eter

iora

tion w

hic

h is

liable

to r

esult in

dan

ger

ous

situ

atio

ns

is insp

ecte

d—

(i)

at

suitab

le inte

rval

s, a

nd

(i

i)

wher

e ex

ceptional

circu

mst

ance

s hav

e occ

urr

ed t

hat

are

lia

ble

to jeo

par

dis

e th

e sa

fety

of

the

work

equip

men

t, a

s so

on a

s

pra

ctic

able

follo

win

g t

hes

e ex

ceptional

circu

mst

ance

s, a

nd

(c

)

without

pre

judic

e to

par

agra

ph (

a),

a w

ork

ing p

latf

orm

—

(i

)

use

d f

or

const

ruct

ion w

ork

, an

d

(i

i)

from

whic

h a

n e

mplo

yee

could

fal

l 2 m

or

more

, is

not

use

d in a

ny

posi

tion u

nle

ss it

has

bee

n insp

ecte

d in t

hat

posi

tion w

ithin

th

e pre

vious

7 d

ays

or,

in t

he

case

of

a m

obile

work

ing p

latf

orm

, in

spec

ted o

n t

he

site

, w

ithin

the

pre

vious

7 d

ays.

(2)

A p

erso

n c

arry

ing o

ut

an insp

ection o

f w

ork

equip

men

t to

whic

h p

arag

raph (

1)(

c) a

pplie

s sh

all—

(a

)

pro

mptly

pre

par

e a

report

conta

inin

g t

he

par

ticu

lars

as

set

out

in S

ched

ule

5,

and

(b

)

within

24 h

ours

of

com

ple

ting t

he

insp

ection,

pro

vide

the

report

, or

a co

py

ther

eof,

to t

he

per

son o

n w

hose

beh

alf

the

insp

ection w

as

ca

rrie

d o

ut.

(3)

An e

mplo

yer

rece

ivin

g a

rep

ort

under

par

agra

ph (

2)

shal

l ke

ep t

he

report

or

a co

py

of

the

report

—

(a)

at

the

site

wher

e th

e in

spec

tion w

as c

arried

out

until th

e co

nst

ruct

ion w

ork

is

com

ple

ted,

and

(b

)

ther

eaft

er,

at a

n o

ffic

e of

the

emplo

yer.

(4)

An e

mplo

yer

shal

l en

sure

that

—

(a)

no w

ork

equip

men

t under

the

emplo

yer’s

contr

ol is

use

d in a

noth

er p

lace

of

work

unle

ss it

is a

ccom

pan

ied b

y ev

iden

ce t

hat

the

last

insp

ection r

equired

to b

e ca

rrie

d o

ut

under

this

Reg

ula

tion h

as b

een c

arried

out,

and

(b

)

the

resu

lt o

f an

insp

ection u

nder

this

Reg

ula

tion is

reco

rded

and k

ept

avai

lable

for

insp

ection b

y an

insp

ecto

r fo

r 5 y

ears

fro

m t

he

dat

e

of in

spec

tion.

Safety, Health and Welfare at Work (Construction) Regulations, 2006

NOTE:

This form is to be used to notify the Health & Safety Authority of any project covered by the Safety, Health and Welfare at Work (Construction) Regulations 2006, which will last longer than 30 days or 500 person days. It can also be used to provide changes to initial notification of projects.

Any day on which construction work is carried out (including holidays and weekends) should be counted, even if the work on that day is of short duration. A person day is one individual, including supervisors and specialists, carrying out construction work for one normal working shift.

This Notification is to be made by Registered Post to HSA, Metropolitan Building, James Joyce Street, Dublin 1; or as may be directed by the Authority.

The project supervisor for the construction stage shall clearly display on the construction site a copy of this form.

Particulars to be notified by Project Supervisor for the Construction Stage to the Health and Safety Authority before the construction work begins

Regulation 22Approved Form (AF 2)

1 Client: Provide name, full address, telephone number and e-mail address for the Client. If more than one Client, please attach details of all Clients on a separate sheet.

Name:

Address:

Telephone: E-Mail:

Description of Project:

Project Supervisor Design Process and Health & Safety Coordinator: Provide name, full address, telephone number and e-mail address for the PSDP and Health & Safety Coordinator for the Design Process.2

PSDP Name:

Address:

Telephone:

E-Mail:

H&S C. Name:

Address:

Telephone:

E-Mail:

Project Supervisor Construction Stage and Health & Safety Coordinator: Provide name, full address, telephone number and e-mail address for the PSCS and Health & Safety Coordinator for the Construction Stage.3

PSCS Name:

Address:

Telephone:

E-Mail:

H&S C. Name:

Address:

Telephone:

E-Mail:

Signed:

Position:

by or on behalf of the Project Supervisor for the Construction Stage

Date:

Information on Construction Work: Please provide your details / estimates for the following.4

The planned date for the commencement of the construction work:

How long the construction work is expected to take (in weeks):

The maximum number of people carrying out construction work on site at any one time.

The number of Contractors expected to work on site.

Information on Construction Work: Provide name, full address & telephone number of those selected to work on this project (if required continue on a separate sheet).5

Name Address Telephone and Email

Address of Site:


Approved Form (AF 3) Regulation 52(3) Regulation 60(2)

Thorough Examination of: (a) Excavations, Shafts, Earthworks, Underground Works or Tunnels; (b) Cofferdams or CaissonsNOTE:

This form is to be used to record the thorough examination of Excavations, Shafts, Earthworks, Underground Works, Tunnels Cofferdams or Caissons. The thorough examination needs to be undertaken at least every 7 days or after an event that may have affected the stability. The thorough examination is in addition to the requirement of a daily inspection of the works.

Indicate the name of the person for whom the report has been prepared.

The approved form may be stoed in a computer and duly authenticated as soon as is practicable afterwards.

Name of Employer or Contractor:

Address of Site:

Description or Location Date of Examination

Results of thorough examination. State whether in good order.

Signature of person who made inspection.

See notes overleaf


Approved Form (AF 3) Regulation 52(3) Regulation 60(2)

Thorough Examination of: (a) Excavations, Shafts, Earthworks, Underground Works or Tunnels; (b) Cofferdams or Caissons

NOTES:General: 1. This form contains the report of the results of any examination of excavations, shafts, earthworks, underground works, tunnels, cofferdams or caissons. 2. The report must be signed by the person carrying out the examination and shall be made on the day of such examination. 3. The report shall be kept on site while work is being carried out otherwise it shall be kept at an office of the contractor for whom the inspection was carried out. Where it is likely that work will not exceed 30 working days in duration, the report may also be kept off-site as indicated above. 4. Regulation 3(4) provides that where under these Regulations records, reports,certificates or other documents are required to be made and kept, it is sufficient compliance with the requirement if the person concerned: (a) enters the record, report, certificate or other document in an approved form in a computer, and; (b) duly authenticates it as soon as is practicable afterwards. Inspection: 5. Excavations, shafts, earthworks, underground works, or tunnels; every part of any excavation, shaft, earthwork, underground works or tunnel where persons are at work must be inspected by a competent person at least once in every day during which persons are at work therein, and the face of every tunnel, the working end of every trench more than 2 metres deep and the base and crown of every shaft must be inspected by a competent person at the commencement of every shift. 6. Cofferdams or caissons in which persons are at work the cofferdam or caisson must be inspected by a competent person at least once every day during which persons are working in the cofferdam or caisson. Thorough Examination: 7. A thorough examination must be carried out: (a) of every part of it within the immediately preceding 7 days. (b) of those parts of it and in particular any shoring or other support, in the region of a blast after explosives have been used in or near the excavation, shaft, earthwork, underground work or tunnel in a manner likely to have affected the strength or stability of that shoring or other support of any part of it. In case explosives have been used in or near the cofferdam or caisson in a manner likely to have affected the strength or stability of the cofferdam or caisson or any part thereof, since the use of the explosives, and; (c) of those parts of it in the region of any shoring or other support of any part of it that has been substantially damaged and in the region of any unexpected fall of rock or earth or other material. In the case of cofferdam or caisson, where the cofferdam or caisson has been substantially damaged. 8. A thorough examination does not have to be carried out: (a) to any excavation, shaft or earthwork where, having regard to the nature and slope of the sides of the excavation, shaft or earthwork and other circumstances, a fall or dislodgement of earth or other material which - (i) would bury or trap a person, or; (ii) would strike a person from a height of more than 1.25 metres is not likely to occur, or; (b) in relation to persons carrying out inspections or examinations required by this Regulation or engaged in shoring or other work for the purpose of making a place safe or construction, placing, repairing or alteration of a cofferdam or caisson, if appropriate precautions are taken, so far as is reasonably practicable, to ensure their safety and health. Published by the Health & Safety Authority, Metropolitan Building, James Joyce Street, Dublin 1 Tel: 1890 289 389


Approved Form (AF 4)Regulation 86(2) Regulation 86(3) Regulation 3(4)

Results of Inspection & Thorough Examination of Personal Flotation DevicesNOTE:

This form is to be used to record the inspection and thorough examination of personal flotation devices (PFD). The inspection of the personal flotation devices must be undertaken in accordance with the manufacturer's instructions. The thorough examination needs to be undertaken at least every 12 months. The thorough examination is in addition to the requirement for inspections.

Indicate the name of the person for whom the report has been prepared.

The approved form may be stored in a computer and duly authenticated as soon as is practicable afterwards.

Name of Employer or Contractor:

Address of Registered Office:

Address of Site:

Description of equipment inspected /

examined, with serial number or

reference number

Date of inspection /

thorough examination

Results of inspection / thorough examination

State condition of personal

flotation device(s)

Comments or action taken

Name (in block capitals) and

signature of person who undertook

inspection / thorough examination

I

E

I

E

I

E

I

E

I

E

I

E

I

E

See further notes overleafEI^ Note: = Inspection = Thorough Examination


Approved Form (AF 4)Regulation 86(2) Regulation 86(3) Regulation 3(4)

NOTES: General: 1. This form contains the report of the results of inspections and thorough examination of Personal

Flotation Devices. 2. Personal Flotation Devices must be Inspected in accordance with the manufactures instructions. 3. Personal Flotation Devices must be Thoroughly Examined every 12 months. 4. The report must be signed by the person making the Inspection or Thorough Examination. 5. The Report shall be kept on site while relevant work is being carried out. 6. Where no relevant work is being carried out on the site the report shall be kept at an office of the

contractor for whom the inspection was made. 7. Regulation 3(4) provides as follows:- Where under these Regulations records, reports, certificates or other documents are

required to be made and kept it is sufficient compliance with such requirement if the person concerned -

(a) enters the record, report, certificate or other document in an approved form in a

computer, and

(b) duly authenticates it as soon as is practicable afterwards. 8. Regulation 86(2) provides as follows:- A contractor responsible for a construction site shall ensure for that site that personal

flotation devices provided in pursuance of this Regulation are -

(a) properly maintained, (b) checked before each use, (c) inspected in accordance with the manufacturer's instructions, and (d) subjected to a thorough examination every 12 months.

9. Regulation 86(3) provides as follows:- On the day of a required inspection or examination under paragraph (2), the person who carries out the inspection or examination, as the case may be, shall -

(a) make a report of the results in an approved form, and (b) sign the report.

Published by the Health & Safety Authority, Metropolitan Building, James Joyce Street, Dublin 1 Tel: 1890 289 389

Results of Inspection & Thorough Examination of Personal Flotation Devices

Type of Incident Reported Date

Yes No Details:

Further Action Required: Yes No

Injury Property / Plant Damage

Near Miss Other………………

Notify to HSA on Form IR1 or IR3?

Details of Incident

Date of Incident Time of Incident

am pm

Name of Witness

Witness Address & Phone Number

Nature of Incident

Location of Incident

Description of Incident

Form 5.1 - Investigation Form

Details of damage to equipment / property?

Details of Injured Person(s) (if applicable)

Name

Address / Phone Number

Employer

Occupation Date of Birth

Details of Injured Person(s) (if applicable)

Name

Address / Phone Number

Employer

Occupation Date of Birth

Recommended Preventative Action

Details

Report Completed By:

Name Position

Signature Date

Form 5.1 - Investigation Form continued

Form 5.2 – Emergency Telephone Numbers

Occupational First Aider Nearest Hospital / A&E Local Doctor Emergency Services• Ambulance • Fire Brigade

112 or 999

Garda Station ESB Networks 1850 372 999 Bord Gáis 1850 205 050 Eircom 1901 Health & Safety Authority

1890 289 389

Assembly Point Please fill in your emergency telephone numbers above and display at your workplace.

Form 5.2 – Emergency Telephone Numbers

Fo

rm 6

.1 - R

isk A

ssess

men

t: T

yp

e 1

Act

ivity

/ w

hat

are

you

doin

gDa

te:

Prep

ared

by:

Iden

tifie

d Ha

zard

Li

st t

he v

ario

us f

acto

rs t

hat

coul

d re

sult

in h

arm

to

the

pers

ons

carr

ying

ou

t th

e ta

sk a

nd /

or

to o

ther

s in

the

vi

cini

ty o

f th

e w

ork

activ

ity. W

alk

arou

nd a

nd a

sk y

our

empl

oyee

s.

Risk

Ass

essm

ent

Low

, Med

ium

or

High

(be

fore

you

put

in p

lace

new

con

trol

s).

Cons

ider

bot

h se

verit

y an

d lik

elih

ood.

Prev

entio

n /

Cont

rol M

easu

res

to

be u

sed

For

each

haz

ard

iden

tifie

d, li

st o

ut t

he v

ario

us

cont

rols

incl

udin

g th

e ne

w /

add

ition

al c

ontr

ol

mea

sure

s th

at a

re t

o be

use

d to

red

uce

and

min

imis

e th

e ris

k of

the

haz

ard

resu

lting

in h

arm

to

bot

h th

e pe

rson

s ca

rryi

ng o

ut t

he w

ork

or

othe

rs w

ho a

re in

the

vic

inity

of

the

wor

k ac

tivity

, to

as

low

as

reas

onab

ly p

ract

icab

le.

Fo

rm 6

.2 - P

roje

ct I

nfo

rmati

on

Sh

eet

Wh

at

Is t

he P

roje

ct N

am

e?

Wh

at

Is t

he P

roje

ct

Ad

dre

ss?

Wh

o I

s M

y S

up

erv

isor?

Wh

at

Work

Have I

to C

arr

y

Ou

t?

Ho

w L

on

g W

ill

the W

ork

T

ake t

o D

o?

Wh

at

Are

th

e D

ail

y

Wo

rkin

g H

ou

rs

Ho

w M

an

y E

mp

loyees

Wil

l B

e W

ork

ing

on

th

e

Pro

ject

?

PSC

S /

Main

Co

ntr

act

or

Deta

ils

PSC

S /

Main

Co

ntr

act

or

Co

nta

ct

Sig

n &

Date

Si

gnat

ure

:___

____

____

____

____

____

____

____

___

Nam

e:__

____

____

____

____

____

____

___

Dat

e:__

____

____

No. Activity Created By Created On

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

34.

35.

Form 6.3 – Site-Specific Risk Assessment Register

Company Name Risk Assessment No.

Date: Task Activity

Prepared By:

Risk Rating Ref. Hazards

High Med Low

1.

2.

3.

4.

5.

6.

7.

Control Measures

1. 7.

2. 8.

3. 9.

.01 .4

5. 11.

Training Requirements Resources Required

Form 6.4 Risk Assessment

Fo

rm 6

.5 –

Pre

-Sta

rt/

Weekly

Ch

eck

list

Fo

rm 6

.5 –

Pre

-Sta

rt /

Weekly

Ch

eck

list

C

om

ple

ted

By

Co

mp

an

y

Ref

No

: It

em N

o

Item

Y

es

No

N/A

1.

?yl efas

kro

w fo ecal

p rieht

o t teg sre

kro

w na

C

2.

?

n i teg t

on

na c c ilb

up e

ht taht

os d ec

nef eti s eht sI

3.

A

re m

easu

res

in p

lace

to p

rote

ct m

emb

ers

of

the

public

(su

ch a

s p

eop

le p

assi

ng

by

the

site

)?

4.

? lle

w til d

na rael c tpek set

uor ciff art e r

A

5.

? se cive

d g

nisrev er y rai lix

u a h ti

w de

ppi

uqe sel ci

hev erA

6.

Is

the

site

tid

y an

d w

ell la

id o

ut?

7.

?)le

nn

osrep

des iro

htua ,set

uor c iffart .

g.e( ecalp

ni sn

gis ytefas etairp

orp

p a e rA

8.

?) steli

ot , sm

oor

gni

gna

hc( tneic if f

u s seit ili ca f ’s rekro

w erA

9.

? )

nee tnac( sl ae

m r ieh t ta e

ot s rek ro

w eht r

of seitilica f e reht e r

A

10

.

?der

usne ec

nall iev ru s

htlaeh sI ,seitil icaf

dia-t srif ereht e r

A

11

.

?g

nild

nah la

una

m ef as n

o de

nia rt d

na de tc

urtsni

n eeb s re

k ro

w evaH

12

. Is

ap

pro

pri

ate

lift

ing

eq

uip

men

t p

rovi

ded

for

han

dlin

g h

eavy

load

s, is

the

equip

men

t su

itab

le f

or

the

job

, ce

rtif

ied

an

d i

nsp

ecte

d o

n a

reg

ula

r b

asis

?

13

.

?deifit

nedi )

daehrev

o ro

de iru

b ( seni l re

wo

p g

nits ixe er

A

14

.

?ec alp

ni senil ci rtc ele evil

ht iw sl ae

d taht kr

ow f

o met sys a ere

h t sI

15

. A

re p

reca

uti

on

s ta

ken

to e

nsu

re t

hat

ele

ctri

cal sy

stem

s an

d e

quip

men

t ar

e m

ain

tain

ed a

nd

fr

equen

tly

insp

ecte

d b

y a

com

pet

ent

per

son?

16

. Is

11

0v

elec

tric

al p

ow

er s

up

ply

bei

ng

use

d a

nd a

re t

her

e ad

equat

e tr

ansf

orm

er p

oin

ts lo

cate

d o

n

site

?

17

.

?elp

oep t

netep

moc y

b delt

namsi

d d

na deretla ,

detcere sdl

offacs erA

18

. A

re s

caff

old

s in

spec

ted a

nd r

esult

s re

cord

ed o

n F

orm

GA

3 a

t re

gula

r in

terv

als

by

a co

mp

eten

t p

erso

n a

nd

req

uir

ed r

emed

ial w

ork

s co

mp

lete

d?

19

. D

o w

ork

ers

use

mob

ile

lad

der

s o

nly

for

lig

ht

work

of

short

dura

tio

n a

nd

when

ther

e is

no o

ther

ch

oic

e?

Fo

rm 6

.5 –

Pre

-Sta

rt/

Weekly

Ch

eck

list

co

nti

nu

ed

20

.

? sr ed

dal e lib

om es

u ot

dna eca l

p o t ya

w tse fas eht

wo

nk sre

kro

w o

D

21

. Is

the

wid

th o

f th

e w

ork

are

a on t

he

scaf

fold

ing

alw

ays

larg

er t

han

the

min

imu

m (

60

cm)?

22

.

?elp

oep t

ne tep

mo c y

b d ekce

hc d

na dell ats

ni yl rep

orp

n eeb stsi

oh

dna st fil eva

H

23

. A

re c

ollec

tive

mea

sure

s in

pla

ce t

o s

top

work

ers

and o

bje

cts

fro

m f

alling

(e.

g.

net

ting

)?

24

. W

her

e co

llect

ive

fall

pro

tect

ion m

easu

res

are

no

t p

oss

ible

, d

o p

erso

ns

work

ing

at

hei

ght

use

ap

pro

pri

ate

fall

arre

st /

res

trai

nt

equip

men

t?

25

. D

o a

ll peo

ple

on t

he

site

wea

r co

rrec

t pro

tect

ive

equip

men

t (e

. g

., f

ootw

ear,

har

d h

at)?

26

. A

re s

uit

able

pro

tect

ive

mea

sure

s use

d t

o p

reve

nt

or

to r

educe

exp

osu

re t

o d

ust

(e.

g.

woo

d,

cem

ent,

sili

ca)?

27

. A

re s

uit

able

pro

tect

ive

mea

sure

s use

d t

o p

reve

nt

or

to r

educe

exp

osu

re t

o n

ois

e an

d v

ibra

tio

n?

28

.

?n

oitid

noc efas a

ni de

niatnia

m y reni

hcam

dna t

nem

piu

qe kro

w sI

29

.

?k ro

w )sdra

ug ,s la

ngis

dn

uo s .

g.e( s ecived ytefas ’s e

nih ca

m eht

oD

30

. A

re e

xca

vati

on

s ad

equat

ely

pro

tect

ed t

o m

inim

ise

the

risk

of

colla

pse

? A

re t

hey

insp

ecte

d w

eekl

y an

d r

ecord

s m

ain

tain

ed o

n F

orm

AF3

?

31

. A

re o

per

ativ

es s

uit

ably

tra

ined

and

in p

oss

essi

on o

f a

valid

FÁ

S C

SCS

card

wher

e ap

plic

able

?

32

. A

re a

ll p

erso

ns

work

ing

on

sit

e in

poss

essi

on o

f a

valid

Saf

e Pa

ss c

ard a

nd

hav

e th

ey b

een

ind

uct

ed?

33

. D

o a

ll em

plo

yees

get

info

rmat

ion a

bo

ut

pote

nti

al r

isk

and

the

esta

blis

hed

pre

venti

ve m

easu

res

in

a la

nguag

e an

d a

t a

leve

l th

at t

hey

und

erst

and

?

Sig

ned

: D

ate

:

Tel. Contractor Name Address

E-mail

Project Name

Description of the Task / Activity

Start Date / Time

Site Address / Location

Finish Date / Time

Name Role / Trade Personnel Involved

Site Supervisor Tel

Safety Officer Tel

Key Plant & Tools (Attach Certification)

Form 7.1 – Method Statement

Key Materials

Other Essential Equipment

(e.g access platforms / winches / ladders, etc)

Specific Identified Residual Hazards (or refer to the task-specific risk assessment(s))

Specific Staff Training

Sequence of Operations (include sketches if required)

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Form 7.1 – Method Statement continued

Fall Protection Measures: (Where work at height cannot be eliminated – consider both Personnel & Materials)

(i.e. Guard Rails/Toe Boards/Brick Guard/Safety Harnesses/Exclusion Zones, etc.)

Very Toxic Harmful/ Irritant

Corrosive Dangerous For the

environment

Oxidising Highly flammable

Explosive

Hazardous Substances: (Attach SDS if required)

Applicable Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No

Storage Arrangements

Details of Permit to Work

SWLs (Detail any limits on the loadings applicable to temporary plant/equipment or fixed elements of the structure wherethe work is taking place)

Safety Boots Hard Hats Safety Gloves Hearing Protection

Eye Protection

Respiratory Protection

Required Personnel Protective Equipment

Applicable Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No

Other:

1. Hi-Viz

2. Coverall

3.

Emergency Procedures

Name of On-Site First Aider

First Aid Box Location

First Aid Facilities

Location of Nearest Hospital


Welfare Requirements

Services to be supplied by others

Other Information & Comments

All work will be undertaken by qualified competent persons with experience of the type of work described above, and in all cases in full accordance with safety procedures specified in my companies health and safety policy.

Items Attached Yes No

Sketches

Certification of Plant etc.

Programme of Work

Risk Assessments

Method Statement Briefing Record

Briefing delivered by:

Position:

Date:

We (the undersigned) have read and understood the attached method statement and will comply with the specified requirements and control measures. If the work activity changes or deviates from that originally envisaged, we will seek further advice and request an amended method statement.

Name Signature Date


Documents

HSA SMP 20 Forms all + blanks 12-5-10