YMBA CIVILS DAILY SAFE TASK INSTRUCTION Document Number

FORM SHE DSTI Form

Rev 0

Company name: YMBA CIVILS AND PROJECT Supervisor:

MANAGERS
Project : Routine Road Maintenance N2 Date:
Weather conditions: Area:

Description of work/activity

DESCRIPTION TO STANDARD CORRECTIVE DATE

Yes No MEASURES
Safe access to work area – clean and tidy
Sufficient / correct barricading erected
Electrical equipment in good condition
Machine guarding adequate
All tools / equipment pre-inspected
Safe access and egress available and used
Scaffolding tagged accordingly
Gas cutting equipment and hoses
Correct PPE (Utilized and available)
Safe working platforms for elevated work
Safe lifting & rigging equipment
SMI lifting & rigging equipment
Correct permits for application
PERMITS valid
Lock-out required & in place?
Correct tools and equipment available
No overhead work allowed
All employees trained accordingly
The list does not exclude and or wave any other checklist and or legal requirements
Risk Assessment Reference No.:
CURRENT JOB WHAT ARE THE HAZARDS LIST CONTROL
List main tasks of job Job & Environment Required/Implemented
1.

2.

3.

4.
 YMBA CIVILS DAILY SAFE TASK INSTRUCTION Document Number
FORM SHE DSTI Form
Rev 0

5.

6.

7.

8.

Note

 If tasks change this list and the Risk Assessment must be revised before proceeding with
new changed task.

Approval

I hereby certify that the above items were checked and all employees under my supervision
received a safe task instruction.
CR 8.7 (Construction
Supervisor)

Name and Surname Designation Signature Date

CR 8(5) Construction
Health and Safety
Officer/ OHS Act Section
17
Name and Surname Designation Signature Date

Pre-Job Acknowledgement Post-Job Confirmation

 YMBA CIVILS DAILY SAFE TASK INSTRUCTION Document Number
FORM SHE DSTI Form
Rev 0

By signing this document, I acknowledge that I
was informed of the hazards associated with
my task and that I understand the content of
this document.
Name & Surname Signature
By signing this document, I declare that I was not
involved in any incident that had an effect on my
health or safety during the task that I performed.
Name & Surname Signature

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.