Section 1 – Task Information and Declaration

Date: Equipment No:

Task Description:
Permit Exempted task? Y N Permit/task Number:
I hereby declare that:
- A permit to work discussion was held (if applicable) and all risks associated with the task were
communicated to the team members. This checklist was completed at the job site before the work starts;
- All hazards identified on the permit (if applicable), the requirements to control the identified risks, task risk
assessment and this checklist were communicated to all involved in performing the task in such a way that no
injury or undesirable event will occur;
- I consider myself and my team members competent to perform this task based on our knowledge and
experience in performing the task;
- I have the correct tools to perform the job and they are in a serviceable condition;
- I will stop work and reassess with my team if conditions have changed during execution of the job that
impact this risk assessment.
- I have observed my own and my team members state of mind by looking out for signs of fatigue, sickness or
absent mindedness (pre-occupation).
Name of Control Number Signature Division / Service Provider
executor/permit
receiver/supervisor

Section 2 – Applicable Life Savings Rules

If the Life Savings Rule is not applicable strike out the whole block. If the Life Saving Rule is
applicable mark “YES” and use the space provided in each block to write down action take to
control the risk. Always check and consider the risks resulting from other activities in the area.

PERMIT TO WORK YES WORKING AT YES LIFTING OPERATIONS YES

HEIGHTS

IGNITION SOURCES/
EXCAVATION / FALL YES CONFINED SPACES YES FLAMMABLE YES
OF GROUND MATERIAL

HH

LOCK-OUT AND YES PPE YES ALCOHOL OR DRUGS YES

ISOLATION

ADHERE TO HEAVY MOBILE

YES ROAD SAFETY YES YES
PROCEDURES EQUIPMENT (HME)

Section 3 – I AM (Task Hazard Check and Risk Assessment)

Study the work site and indicate the presence or absence of the hazards listed in the “Identify
Hazards” table below. Any other hazards not listed in the table should be added in the “other
Hazards” section of the table. Each hazard is numbered. Discuss with team and agree on what can go
wrong and actions to control the risk. Write the hazard number, assess what can go wrong and
manage by taking steps to control the risk. Adhere to hierarchy of risk controls (Elimination,
Substitution, Engineering controls, Administrative/signage and PPE). Assess if the steps taken control
the risk to an acceptable level by indication Y (Yes) or N (No). Only start job once all risks have been
removed or plans are in place to safely control identified risks

Identify hazards
No. Hazard Present No. Hazard Present
1 Pinch Points 9 High Pressure Hoses / equipment
2 Obstructions 10 Flying pieces/objects possible
3 Slipping Hazards 11 Space limitations/ergonomics
4 Tripping Hazards 12 Impact tools used
5 Falling Objects 13 Person/s may get in “line of fire”
6 Sharp Edges 14 Communication difficulties
7 Uneven Surfaces 15 Exposure to Hazardous Chemical Substances
8 Hot Surfaces / Steam / 16 Other work in area
Condensate
Other Hazards (List)
17 Noise 22
18 23
19 24
20 25
21 26

K
 No. What can go wrong (Assess) Steps taken to control risk at acceptable level that will
prevent injury (Manage)

Section 4 - Emergency Points and Facilities

Use the plot plan on the left to clearly indicate your team’s location as well as the escape route to the
nearest assembly point/ ambulance point. In the table below, write down the relevant number.
Where not applicable, indicate in the number column by marking N/A. Remember to communicate
this to all the team members.
Equipment Type Number Remarks

Emergency Shower
Eye Baths
Assembly Points
Escape Routes
Ambulance Points

Section 5 - Acknowledgement of Communication and Understanding of Task Risks

Team members sign to indicate that task risks as identified on work permit, task risk assessment and
this checklist as well as the risk control measures have been communicated to him/her and that
he/she understands it and knows how to avoid injury or unwanted events.