SAFETY PLANNING CHECKLIST

Your name

This form needs supervisor verification. If you are not the supervisor, who is the site supervisor?

Current location

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Select project

Is site affected by overnight conditions, eg weather, vandalism, theft, removal of materials/barricades etc?

Yes No Not Applicable

Pipe caps in place for pipes u2264200mm diameter? Valves & fittings covered/protected prior to installation?

Yes No Not Applicable

Any failure to Non Disinfection Guidelines

Yes No Not Applicable

If failure has occurred has Superintendent been notified?

Yes No Not Applicable

Safe Work Method Statements (SWMS) + SWP/EMP review

Safe Work Method Statements (SWMS) + SWP/EMP review ( a ) Any new risks due to changes in work environment?

Yes No Not Applicable

Safe Work Method Statements (SWMS) + SWP/EMP review ( b ) Is different plant and equipment to be used today?

Yes No Not Applicable

Safe Work Method Statements (SWMS) + SWP/EMP review ( c ) Are all today's work activities covered in the SWMS + SWP/EMP?

Yes No Not Applicable

Safe Work Method Statements (SWMS) + SWP/EMP review ( d ) Are any new chemicals or materials coming today?

Yes No Not Applicable

Safe Work Method Statements (SWMS) + SWP/EMP review ( e ) Are there any new workers/subcontractors requiring induction?

Yes No Not Applicable

Are there any changes to road or traffic conditions?

Are there any changes to road or traffic conditions? ( a ) Stormwater protection correctly installed/fit?

Yes No Not Applicable

Are there any changes to road or traffic conditions? ( b ) Erosion and sediment controls correctly installed/fit?

Yes No Not Applicable

Are there any changes to road or traffic conditions? ( c ) Tree protection in place

Yes No Not Applicable

Are there any deliveries today? List any instructions

Yes No Not Applicable

Are there any deliveries today? List any instructions

Yes No Not Applicable

Dial Before You Dig plans have been viewed and discussed with worker's/subcontractors?

Yes No Not Applicable

Daily plant and equipment checks have been done, log books and registers filled out? (Check slings, chains, safety harnesses, gas detectors etc. as well as machinery)

Yes No Not Applicable

Does everyone have the right PPE & appropriate licences for the job today?

Yes No Not Applicable

Is public access and thoroughfare in good condition?

Yes No Not Applicable

Are traffic & pedestrian controls signs uncovered/in place?

Yes No Not Applicable

Is all penetrations still securely covered & tagged?

Yes No Not Applicable

Are specific fall protection controls required prior to removal of covers over penetrations/trenches etc?

Yes No Not Applicable

Is first aid box and first aider and MSDS on site?

Yes No Not Applicable

Is fire protection, spill kit/material available on site?

Yes No Not Applicable

Excavations, shoring and access ladders safe?

Yes No Not Applicable

Is there any potential for a person to fall over 1.8m?

Yes No Not Applicable

Site has been checked by the crew supervisor as clean and safe for public at the completion of works for the shift.

Yes No Not Applicable

Check and record here the lowest point of clearance of O/H Powerlines and other services you are working under today: eg House 32 = 3.5m

Any other issues/discussion/suggested improvements for site management today:

Comments/Actions/agreed changes/not applicable

Date

Your signature

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Supervisor Signature

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Supervisors signature ( if you are the supervisor, sign again )

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SAFETY PLANNING CHECKLIST

Safe Work Method Statements (SWMS) + SWP/EMP review

Are there any changes to road or traffic conditions?

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