Name:

Date from: Date to:

5Take 5REAL TIME SAFETY ANALYSIS AND INCIDENT REPORT

Steps to safety

ww

w.u

nip

rint.

com

.au

SAMPLE

Before starting work, a Safe Work Method Statement (SWMS) must be completed if your work involves any High Risk Construction Work or Common Hazards where someone's health and safety are at risk.

Stop, step back and think1

4 Referring to the 'Hierarchy of Controls'.Control the Hazard(s)

3 Referring to the 'Hazard Risk Rating Table'.

Referring to the 'Hierarchy of Controls'.Control the Hazard(s)

Referring to the 'Hazard Risk Rating Table'.Assess the level of Risk

ACTION PLAN High-risk construction hazards:

– Working at heights of more than 2 metres– Demolition– Removal or disturbance of asbestos– Diving– Trenches or shafts deeper than 1.5 metres– Temporary supports for structural alterations– Powered mobile plant– Explosives– Con!ned spaces– Tunnels– Tilt-up or precast concrete

or construction work that is in, or near:– Electrical installations or services– Roads or railways in use by tra"c– Water/liquids that pose a drowning risk– Telecommunications towers– Pressurised gas distribution mains or piping– Arti!cial temperature extremes– Contaminated or #ammable atmospheres– Chemical, fuel or refrigerant lines

HIGH RISK CONSTRUCTION WORK

2 For High Risk Construction Work refer to your SWMS, for theCommon Hazards complete a condensed SWMS.

Assess the level of Risk

For High Risk Construction Work refer to yo

Common Hazards complete a condensed SW

Identify the Hazard(s)

Always follow your SWMS, if job tasks change or injury occurs go back to step 1.

arting work, a Safe Work M

Construction Work or

Always follow your SWMS, if if jo

occurs go back to step 1.

Proceed Safely5 SAMPLE

YES NO

Date:Job Reference:

Location: Task:

Time:Time: am / pm

Do I understand what I need to do?

Do I need a SWMS for any 'High Risk Construction Work'?

Do I need any permits (e.g. hot work/confined space/dig)?

Do I have the correct PPE in good condition for the task?

Do I have the suitable tools and equipment for the task?

Do I have my vehicle parked appropriately?

Am I trained, competent, licensed and fit to perform this task?

YES NO

Manual Handling (e.g. Lifting, awkward positions, impacts, over-exertion)

Gravity (e.g. Slips, trips and falls and struck by falling objects)

Mechanical (e.g. Caught in moving parts, struck by plant or flying objects)

Electrical (e.g. Electrocution from faulty tools or working close to live power)

Chemical (e.g. Inhaling, swallowing or touching acid, solvents or asbestos)

Pressure (e.g. Contact with highly pressurised fluid/gas or air)

Noise (e.g. Hearing damage, masking of emergency alarms)

Biological (e.g. Contracting diseases e.g. Hepatitis and Legionnaires)

Radiation (e.g. Exposure to radiation such as x-rays, sunlight or ultra-violet)

Psychological (e.g. Stress, violence, fatigue, depression)

Heat and Cold (e.g. Working with hot or cold objects or exposure to environment)

Assess the level of risk3Risk(s) worked out? YES NOSWMS completed YES NO

Proceed safely5Safe to proceed

Control the hazards4

Stop, step back and think1 YES NO Identify the hazard(s)2 If you tick a bold square, turn overand complete the SWMS form

SAMPLE

Name/s:

Date:Signature/s:

What are the hazards and risks? How will hazards and risks be controlled?Risk

Rating

Refer to the Risk Matrix and Hierarchy of Controls at the back of the book

SAFE WORK METHOD STATEMENT (SWMS)4 IF NO HAZARD EXISTS – NO RISK OF INJURY OR ILLNESS EXIST

SAMPLE

The Master PlumbersAssociation recognises the vital role plumbingplays in supporting members, developingand maintaining publichealth and ensuringthe environmentalsustainability of our communities.

www.plumber.com.au

Our mission is to provide members with training, advice and services that are aligned to their business needs.

From commercial business and professional development opportunities, advice on employment and safety and a huge range of industry, technical, business and environmental training.

Becoming a member of the Master Plumbers Association will ensure you stay ahead of the game.

Find out more by contacting our Membership Services Team on (03) 9329 9622.SAMPLE

Name:Date from: Date to:

5

Take 5

REAL TIME SAFETY ANALYSIS

AND INCIDENT REPORT

Steps to safety

ww

w.u

nipr

int.c

om.a

u

UniPrint Pty LtdCommercial Printers

13 Edinburgh StreetOakleigh South VIC 3167

Phone: 03 9543 7677 Fax: 03 9544 2748

Feedback...Have you used our on-lineTake 5 training?

We’d love to get your feedback.Go to our website for more detailsuniprint@uniprint.com.au…for all your needs in innovative workplace documentation

Take 5

SAMPLE

Location

Name of injured person

What happened (include injury details and property damage)?

Self Employee Contractor Visitor

INCIDENT/INJURY REPORT Date: Time: am/pmIncident Injury

SAMPLE

What actions have been taken (include any first aid)?

Has the worksite been secured or made safe to continue?

What can be done to prevent it happening again?

Name: Signature:

Witnesses and contact details

Secured Safe to proceed

Do you need to inform any authorities? Worksafe Insurance Employer Association

SAMPLE

HAZARD RISK RATING TABLEMatrix sourced from AS/NZS 4360.2004 – Risk Management Consequence Rating (How severe is the potential harm?)Lik

elih

ood

Ratin

g (H

ow lik

ely is

it to

happ

en?)

Expected to occur in most circumstances.

1

A

B

C

D

E

2 3 4 5

CatastrophicDeath/Disability

High risk

High risk

High risk

Medium risk

Medium risk

High risk

High risk

High risk

Medium risk

Medium risk

High risk

Medium risk

Medium risk

Medium risk

Medium risk

Medium risk

Medium risk

Medium risk

Low risk

Low risk

Medium risk

Medium risk

Low risk

Low risk

Low risk

Certain to occur

Will probably occur in most circumstances.

Very likely

Might occur occasionally.Possible

Could happen at some time.

Unlikely

May happen only in exceptional circumstances.

Rare

MajorHospitalisation

ModerateMedical treatment

Insigni!cantNo threat of injury

MinorFirst Aid injury

High risk Workplace Manager agrees with control(s). Medium risk Workplace Supervisor agrees

with control(s). Low risk Tradesperson in charge agrees with control(s).

SAMPLE

HIERARCHY OF CONTROLS

Printed by UniPrint Pty Ltd under license from Master Plumbers’ and Mechanical Services Association of Australia13 Edinburgh Street, Oakleigh South, Victoria 3167 Ph: 03 9543 7677 Fax 03 9544 2748 www.uniprint.com.au August 2013

ELIMINATE

SUBSTITUTE

ENGINEER

PPE

What equipment/machinery can we use to remove and/or isolate the hazard? (e.g. Enclose or isolate the

hazard by fitting a guard.)

Can we remove the hazard so it no longer exists? (e.g. Cease a dangerous

work practice.)

How can we do the job another way to remove the hazard? (e.g. Replace the chemical

with a less hazardous one.)

What safety rules, training or signs will minimise exposure to the hazard? (e.g. Use tra!c management procedures.)

What personal protective equipment can be used to minimise exposure to the hazard? (e.g. Wear ear mu"s.)

ADMINISTER

SAFE PLACE

SAFE PERSON SAMPLE