Proposed Work         Name Of Person Notified  
 
Has Production Been Notified?
 
Has Authorised Person Been Notified?
 
Name of Authorised Person Phone SAP Number  
   
     
HAZARD IDENTIFICATION CONTROLS REQUIRED RISK RANK
(with controls in place) 		CONTROLS/PRECAUTIONS (number list)  
Person Risk   Physical Isolations PPE  
Confined Space 1. Electrical 23. Sire Standard PPE  
Lone Worker   2. Steam Safety Helmet  
Restricted Access 3. Hydaulic Safety Boots  
Electrical   4. Pneumatc Safety Glasses  
In Wall / U Grnd Srvces 5. Barricading High Vis Vest  
Fire/Explosion   6. Traffic Management 24. Face Shield  
Mobile Plant   7. Other 25. Chemical Goggles  
Pressure/Vacuum 26. Welding Helmet  
Heat Source     27. Hearing Protection  
Overhead Hazards Plant & Equip 28. Respirator  
Working at Height 8. Boom Lift 29. P2 Dust Mask  
Objects Falling   9. Scissor Lift 30. 2 Wayradio/Mobile
Noise   10. Forklift 31. Wet weather Gear  
Manual Handling 11. Scaffold 32. Ice Vest  
Moving Machinery 12. Ladder 33. Saftey Harness Lifeline
Uneven Slippery Surfaces 13. Barricade 34. Spill Containement Equip
Asbestos / SMF   14. Fan 35. Riggers Gloves  
Sun UV Rain Wind 15. Rigging Lifting Gear 36. Kevlar Gloves  
Poor Housekeeping 16. Other 37 Chemical Gloves  
Poor Lighting   38. Other  
Gas Hazard      
 
Environment   Permits Required Personnel Required  
Spills/Pollution 17. Confined Space 39. Safety Watch  
Flora Fauna Impact 18. Hot Work 40. Rigger  
Chemicals /MSDS 19. High Voltage 41. Crane Driver  
  20. Ground breaking 42. Forklift Driver  
Other Hazards   21. Roof Access 43. Electrician  
1   22.Other 44. Plumber  
2   45. Mechanical Fitter  
3     46. Boilermaker  
4     47. Other  
   
 
Please Note: If A "H - High" is selected For RISK RANKING SCORE - You MUST complete a JSEA!  
 
JOB SPECIFIC INSTRUCTIONS EQUIP FOR ISOLATION ISOLATION TAG No Reviewed By Work Team Initial
 
 
 
 
AUTHORISATION TO PROCEED We have carried out a Job Hazard Assessment and agree the Work May Proceed
Team Member Sign Supervisor Sign  
           
 
END OF WORK To be signed off on completion  
 
 
 
Isolations Signed off   Guards All back in Place  Tools and Euip House Keeping Ok