SPA FORM

Recipient

example@example.com

TODAY'S DATE*

LOCATION

MAIN CONTRACTOR

TASK*

COMPLETED BY*

RISK ASSESSMENT AND METHOD STATEMENT REFERENCE*

EMERGENCY CONTACT NUMBER*

NUMBER OF PERSONNEL ON SITE*

SUPERVISOR NAME

SUPERVISOR NUMBER

NEAREST EXTINGUISHER KNOWN

YESNO

Site Requirements (All Documentation MUST Be Valid)*

Permits Needed

Plant Required

Tools Required*

Risk Identification*

Hazard Identification

Required Controls*

PPE Required*

HAVE THE PERSONNEL INVOLVED IN THIS TASK BEEN BRIEFED OF THE COVID-19 SITE SPECIFIC RISK AND IS IT POSSIBLE TO COMPLY WITH THE STANDARD PROCEDURES AS OUTLINED BY THE HSE.

*IF NO, PLEASE NOTE(*B)

(*B) WHAT SPECIAL CONTROL MUST BE IN PLACE TO MINIMISE THE RISK:

IF SOCIAL DISTANCING IS NOT POSSIBLE, MINIMUM PPE IS GLASSES, MASK AND GLOVES

HSE COVID-19 COMPLIANCE

YESNO

WAS A TOOLBOX TALK CARRIED OUT?*

YESNO

WHAT TOPIC WAS DISCUSSED?

File Upload

Subcontractor 1

First NameLast Name

Signature 1

Subcontractor 2

First NameLast Name

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Subcontractor 3

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Subcontractor 4

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Subcontractor 5

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Subcontractor 6

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Subcontractor 7

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Subcontractor 8

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Subcontractor 9

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Subcontractor 10

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Subcontractor 11

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Subcontractor 12

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Subcontractor 13

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Subcontractor 14

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Subcontractor 15

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Subcontractor 16

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Subcontractor 17

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Subcontractor 18

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Subcontractor 19

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Subcontractor 20

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Subcontractor 21

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Subcontractor 22

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Subcontractor 23

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Subcontractor 24

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Subcontractor 25

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Subcontractor 26

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Subcontractor 27

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Subcontractor 28

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Subcontractor 29

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Subcontractor 30

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Have I looked and identified all the hazards?

YESNO

Will the job / task be done as before?

YESNO

Are the resources (PPE, tools, operatives) still available?

YESNO

Can the job be done without causing an accident?

YESNO

Is everything the same since I last did the job / task?

YESNO

Are other operatives protected from my activities area?

YESNO

Do I know emergency points / locations / protocols?

YESNO

Do I have safe access / egress from my work area?

YESNO

Is my work area clean and tidy?

YESNO

Have I checked if there are critical risk activities in the task?

YESNO

Supervisors Name

First NameLast Name

Supervisors Signature

SAFE PLAN OF ACTION

REQUIRED TRAINING & DOCUMENTATION

PERMITS REQUIRED

PLANT USAGE

TOOLS USAGE

RISKS

HAZARDS

CONTROLS

PPE

COVID-19 COMPLIANCE

TOOLBOX TALK

OPERATIVE SIGN-OFF

SUPERVISOR SIGN-OFF