Why am I using this tool?
If "Other" please specify
Who is conducting the work?
Where is the work taking place?
What work is taking place? (start with a job title, then bullet point your method)
Don't forget to check other works going on in the area!
Who are at risk?
Is a two man team required?
What HAZARDS could I face?
Any other HAZARDS?
Do I need a Permit-To-Work
Permit number (if used)
What do I need to LOTO?
LOTO number if used
What PPE do I need?
Control measures that have been taken to reduce the risk
Are there any more control measures that must be implemented to minimise risk before work starts?
Work Equipment & Factors Effecting Work
Do I have the correct equipment?
Is the equipment inspected and free from defect?
Do I have safe & easy access to the work area?
Do I have safe & easy access to my equipment?
Is there sufficient lighting?
Am I competent to conduct this task?
Am I medically fit for this job?
Can I summon help if I get hurt?
Am I aware of the emergency procedure and equipped to deal with one?
Do I need to inform anyone else?
If "No" has been selected above, state what action has been taken
ONLY PROCEED IF YOU ARE SURE YOU CAN DO THE JOB SAFELY! IF IN DOUBT, STOP AND SEEK ADVICE!
I am content that all reasonable and practicable control measures have been made to minimise risk
Click here to sign
Overall risk category (post implementation of control measures)
Source: Dugdale (Community Member)