JOB HSE PLAN

Activity No. Activity Description

(Note: Refer and follow relevant
company procedure for this activity)

Location:

Tasks Hazard Control Action Party *

* Work Supervisor on site is to confirm ( ) that all controls are in place prior to start the job.

JOB SAFETY PLAN CONTENT AGREED

Permit Applicant: Signature: Date:

Responsible Supervisor: Signature: Date:

BRIEFING OF HOLDER BY APPLICANT AND ACCEPTANCE BY HOLDER

I have been briefed on the hazards and controls involved in the work and on any other necessary information and
the Controls specified in this Job Safety Plan will be applied during the work.

Time:

Permit Holder: Signature: Date:

ACCEPTANCE BY AREA AUTHORITY

The Controls specified in this Job Safety Plan and any additional controls required are in place.

Time:

Area Authority: Signature: Date:

Date Printed: 16/12/2021 05:56:15 Page: 1 of 1