Take Five
Prestart Form
Date
-
Month
-
Day
Year
Date
Site Address
Person completing the take five
First Name
Last Name
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Do I have the required skills and knowledge to complete the task safely?
*
Yes
No
Do I fully understand all aspects of the work?
*
Yes
No
Am I fit for work, competent and authorised to perform the task?
*
Yes
No
Am I aware of the emergency procedures and do I have the means to activate them if needed? (i.e. mobile phone or radio)
*
Yes
No
Have I ensured that the task will not impact on the environment/community? (i.e. dust, spills and noise)
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Yes
No
I have identified and isolated all sources of energy?
*
Yes
No
Are my tools and equipment suitable for the task and in a safe operating condition?
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Yes
No
Is my PPE suitable for the task, do I know how to use it and is it in good condition?
*
Yes
No
Am I aware of other people and equipment in my work area and have I communicated with them?
*
Yes
No
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Site Hazards identified
*
Electrical
Slips/Trips
Public
Hot works
Power/Hand tools
Work outdoors
Falling objects
Hazard manual tasks
Working at heights
Mobile plant
Dangerous animals
Atmospheric contaminants
Lighting
Young workers/Apprentices
Access and egress to site
Lifting/Suspending equipment
Scaffold erection/Dismantle
Flammable & combustible substances
Dangerous goods/Hazardous substances
Other
Are all identified hazards covered by the SWMS?
*
Yes
No
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Control Measures
*
1. Use of proper PPE i.e. hats, sunscreen, gloves, sunglasses, long sleeve shirts, ear plugs and covered footwear. 2. Water available on site. 3. Test equipment checked for correct operation before use. 4. Ladder secured. Ladder checked for cracks and damaged feet. 5. Harness checked in date, and set up correctly, for use if needed. Edge protection installed at working edges. 6. Exclusion zones set up in drop areas. 7. Correct lifting techniques at all times. 8. Proper supervision for apprentices, apprentices not to complete testing or verification. 9. Material data sheets available at all times.
Signature
Contractor Email for PDF copy of report
example@example.com
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