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ACTIONS SYSTEM
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2020-09-06T20:30:07+00:00
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Safety Forms
Quality Forms
Enterprise Forms
Human Resources Forms
SAFETY:
Safety Event Report
Hazard Report
Investigation Level 1
PPE inspection
Vehicle Inspection
Contractor Selection
Equipment Commissioning Checklist
Job Safety Analysis
Safety Observation
QUALITY
Equipment Acceptance Certificate
No Conformance Report
ENTERPRISE
Risk Assessment
PCBU Meeting Record
Level 1 Investigation
Risk Management Plan
Assurance Plan
Change Plan
Communications Plan
Annual Plan
HUMAN RESOURCES
Competency Assessment
Training Plan
Injury / Illness Rehabilitation
Induction Form
Equipment Commissioning Checklist
Name of person Completing the Checklist:
Name of Item Being Commissioned
Description of Item Being Commissioned
Date Equipment Planned for Commissioning
HAS THE FOLLOWING BEEN COMPLETED:
AS/NZ 4024 Standard Met
Assessment against AS/NZ 4024 Completed
Yes
No
Date AS/NZ 4024 Assessment Completed
Maintenance Programme Prepared
Yes
No
Maintenance Programme Completed
Yes
No
Following Maintenance Documentation Provided:
Preventative Maintenance Plan
Electrical Certification
AS/NZ 4024 Certificate
Date Maintenance Programme Completed
Equipment Certified to AS/NZ 4024
Yes
No
Date Equipment Certified
HAS THE FOLLOWING DOCUMENTATION BEEN PREPARED:
Have SOPs / Safe Systems of Work
SOPs / SSoW Prepared
Yes
No
ACOP Requirement Met:
Yes
No
N/A
Date SOPs Completed
Training Requirements
Training Plan Prepared
Yes
No
Training Implemented
Yes
No
Date Training Completed
Risk Management
Risk Assessment Completed
Yes
No
Date Risk Assessment Completed
Risk Management Plan Prepared
Yes
No
Plan Not Required
Assurance Plan Prepared
Yes
No
Equipment Tested
Yes
No
Date Risk Management and Assurance Plans Completed
Commissioning Approval
All Requirements Satisfied
Yes
No
Date All Requirements Completed
Commissioning Approved
Yes
No
Date Commissioning Approved
Name of Person Approving Commissioning
Appointment of Person Approving Commissioning
Please fill in all fields to be able to Submit
Logged By
Please select
Jon-Brian Parker
Jim Pope
John Graumans
Carol
Christine
Name of Person
Please select
Jon-Brian Parker
Jim Pope
John Graumans
Contractor
Carol
Christine
Item Inspected
Please select
Boots
Eye Protection
Item Serial Number
Item State
Inspection Result
Please select
Passed
Failed
Recommendations
Date of next Inspection
Logged By
Please select
Jon-Brian Parker
Jim Pope
John Graumans
Carol
Christine
Which Vehicle
Please select
VW Passet - KRR64
Hyundai i30 - HWL23
Ford Courier - HLY507
Tandem Trailer - S952Y
Nissan Forklift -
Hyster -
Milage
Fuel Type
Petrol
Diesel
Other
RUC
WOF Current
Yes
No
Date
Registration Current
Yes
No
Date
Windows'
Undamaged
Yes
No
Windows are Clean
Yes
No
Vehicle Panels are un damaged
Yes
No
Engine
Oil Level correct
Yes
No
Fan belt correctly tensioned and undamaged
Yes
No
Are there any Oil Leaks
Yes
No
Is Coolant level between Min - Max and coloured
Yes
No
Spare wheel is in place, inflated and in good repair
Yes
No
Wheel changing kit in place and complete
Yes
No
First Aid kit in place and complete
Yes
No
Fire Extinguisher in place and charged and not outside expiry date
Yes
No
Tyre Status
Correctly Inflated
Yes
No
Undamaged
Yes
No
More then minimum tread depth
Yes
No
Lights Status
Work on Full Beam
Yes
No
Work on Dip
Yes
No
Tail lights working
Yes
No
Brake lights working
Yes
No
Indicators working
Front - Yes
Front - No
Rear - Yes
Rear - No
Wiper Blades are in good repair
Yes
No
Wiper Blades are working
Yes
No
Reservoir is Full
Yes
No
Seat Belts Condition
Good
Damaged
Seat Belts Working
Yes
No
Interior Cleaning
Yes
No
Date of next Inspection
Report Logged By:
Date Event Occurred
Safety Event Type
Please select
Near miss
Injury
Type of Near Miss
Please select
None of the following
Escape, Spillage or Leakage of a Substance
Implosion, Explosion or Fire
Escape of Gas or Steam
Escape of a Pressurised Substance
Electric Shock
Fall or Release from Height of any Plant Substance or Thing
The Collapse, Overturning, Failure, Malfunction of or Damage to any Plant required to be Authorised for use in accordance with regulations
Collapse of partial Collapse of a Structure
Collapse of Failure of an Excavation or Shoring of an Excavation
Inrush of Water, Mud or Gas in workings in an Underground Excavation of Tunnel
Interruption of the Main System of Ventilation in an Underground Excavation or Tunnel
A Collision between two vessels, vessel capsize or inrush of water into a Vessel
Name of Injured Person
What injuries were sustained?
*
Provide a detailed description of what injuries were sustained and treatment provided.
Were the Injuries any of the Below:
*
Please select
None of the Below
A Serious Burn
An Injury requiring hospital treatment with in 48hrs of a substance
An Injury requiring immediate hospital treatment
The Lose of Bodily Function
A Serious Head Injury
A Serious Eye Injury
An Amputation
A Spinal Injury
An Illness requiring immediate hospital treatment
An Illness requiring hospital treatment within 48hrs of a substance
A Serious Infection
Death
Has The Scene Been Secured?
Yes
No
SECURE THE SCENE
Event Description
*
Provide a detailed description of what occurred and actions taken
Event Location
Please select
Zone 1
Zone 2
Zone 3
Witnesses' Name/s
List the names and contact details of all witnesses and those who were involved in the event.
Logged By
Please select
Jon-Brian Parker
Jim Pope
John Graumans
Carol
Christine
Hazard Title
Location
Please select
Zone 1
Zone 2
Zone 3
Hazard Description
Who could be harmed ?
What harm might occur ?
How might harm occur ?
Assessment Completed By:
Company Name
Date Application Received
Contract Work to be Undertaken / Services to be Provided
Name of Company Point of Contact
Have the Following Documents Been provided?
Safety Manual
Yes
No
Evidence of Worker Competence
Yes
No
Populated Risk Register
Yes
No
Documented SOPs / Safe Systems of Work / Procedures
Yes
No
Documented Emergency Procedures
Yes
No
Documented Emergency Procedures
Yes
No
Copy/s of Safety Committee Meetings
Yes
No
N/A
Copies of any JSAs /JSEAs / SSSPs
Yes
No
N/A
Evidence of Assurance Activities
Yes
No
N/A
Reporting Procedures
Safety Event Reporting Procedures Provided?
Yes
No
Hazard Reporting Procedures Provided?
Yes
No
Quality Management Reporting Procedures Provided?
Yes
No
Has the Company Issued PPE to their Workers?
Yes
No
Not Declared
Have The Following Insurance Certificates Been Provided?
Public Indemnity
Yes
No
N/A
Professional Indemnity
Yes
No
N/A
Vehicle
Yes
No
N/A
Statutory Indemnity
Yes
No
N/A
Prosecution Details
Has the Company ever been Prosecuted or does it have prosecutions pending by WorkSafe?
Yes
No
What are the Prosecution Details
Assessment Outcome
Approved
More Information Required
Not Approved
Date Assessment Completed
Comments
Training Plan
JSA Completed By:
Date
Job Location
Job Details
Safety Risk Tolerance Level
Very High
High
Medium
Low
Task Analysis
Task 1
Response Action
Eliminate
Minimise
Task Steps
Raw Risk Assessment
Very High
High
Medium
Low
Controls
Residual Risk Assessment
Very High
High
Medium
Low
Are There Any More Tasks?
Yes
No
Task 2
Response Action
Eliminate
Minimise
Task Steps
Raw Risk Assessment
Very High
High
Medium
Low
Controls
Residual Risk Assessment
Very High
High
Medium
Low
Are There Any More Tasks?
Yes
No
Task 3
Response Action
Eliminate
Minimise
Task Steps
Raw Risk Assessment
Very High
High
Medium
Low
Controls
Residual Risk Assessment
Very High
High
Medium
Low
Are There Any More Tasks?
Yes
No
Task 4
Response Action
Eliminate
Minimise
Task Steps
Raw Risk Assessment
Very High
High
Medium
Low
Controls
Residual Risk Assessment
Very High
High
Medium
Low
Are There Any More Tasks?
Yes
No
Task 5
Response Action
Eliminate
Minimise
Task Steps
Raw Risk Assessment
Very High
High
Medium
Low
Controls
Residual Risk Assessment
Very High
High
Medium
Low
Are There Any More Tasks?
Yes
No
Task 6
Response Action
Eliminate
Minimise
Task Steps
Raw Risk Assessment
Very High
High
Medium
Low
Controls
Residual Risk Assessment
Very High
High
Medium
Low
Are There Any More Tasks?
Yes
No
Task 7
Response Action
Eliminate
Minimise
Task Steps
Raw Risk Assessment
Very High
High
Medium
Low
Controls
Residual Risk Assessment
*
Very High
High
Medium
Low
Are There Any More Tasks?
Yes
No
Task 8
Response Action
Eliminate
Minimise
Task Steps
Raw Risk Assessment
Very High
High
Medium
Low
Controls
Residual Risk Assessment
Very High
High
Medium
Low
Are There Any More Tasks?
Yes
No
Task 9
Response Action
Eliminate
Minimise
Task Steps
Raw Risk Assessment
Very High
High
Medium
Low
Controls
Residual Risk Assessment
Very High
High
Medium
Low
Are There Any More Tasks?
Yes
No
Task 10
Response Action
Eliminate
Minimise
Task Steps
Raw Risk Assessment
Very High
High
Medium
Low
Controls
Residual Risk Assessment
Very High
High
Medium
Low
Workers Briefed:
Yes
No
Visitors Briefed:
Yes
No
Names of Workers Briefed
Supervisors Name
Safety Observation Report
Date of Observation
Person Making the Observation
Person Observed
Details of Observation
Was an Intervention Required?
Yes
No
Details of Intervention Taken
Are There Any Recommendations?
Yes
No
Recommendations
Equipment Acceptance Certificate
Non-Conformance Report
Enterprise
Attendee's
Location
Scope of work
Points of contact
KTD and other PCBU's
Responsibilities for safety
KTD and other PCBU's
Responsibilities for Quality
KTD and other PCBU's
Reporting Requirement's
KTD and other PCBU's
Induction Requirement's
KTD and other PCBU's
Worker Competence
KTD and other PCBU's
Dispute Resolution Process
KTD and other PCBU's
Assurance Activities'
KTD and other PCBU's
Risk Management
KTD and other PCBU's, Safety and Quality Risk's
Investigation's
Meeting Schedule
Process Procedure's for Common Use
Insurance Requirements
KTD and other PCBU
Emergency Management Requirements
KTD and other PCBU
General Matters
KTD and other PCBU
Date Risk Reviewed
Risk Perspective
Please select
Safety
Quality
Enterprise
HAZARD INFORMATION
Hazard Title
Hazard Description
Who could be harmed ?
What harm might occur ?
How might harm occur ?
Hazard Location
Please select
Zone 1
Zone 2
Zone 3
ISSUE INFORMATION
Issue Title
Issue Description
Effect of Issue
RISK PERSPECTIVE AND RESPONSE
Risk Perspective
Safety
Quality
Enterprise
Threat or Opportunity
Threat
Opportunity
Response Option
Safety
Eliminate
Minimise
Threat
Avoid
Reduce
Share
Accept
Opportunity
Exploit
Enhance
Share
Reject
Current Control Effectiveness
Control Name
Control Effectiveness
Fully Effective
Partially Effective
Not Effective
Control
Control Effectiveness
Fully Effective
Partially Effective
Not Effective
Factors
Raw Risk Assessment
Raw Risk Likelihood Assessment
Almost Certain
Likely
Possible
Unlikely
Rare
Raw Risk Impact Assessment
Not Significant
Minor
Moderate
Major
Severe
CONTROLS
Changes to Current Controls
New Controls
Residual Risk Assessment
Residual Risk Likelihood Assessment
Almost Certain
Likely
Possible
Unlikely
Rare
Residual Risk Impact Assessment
Not Significant
Minor
Moderate
Major
Severe
RISK ACCEPTANCE AND PRIORITY
Risk Accepted
Yes
No
Priority
1
2
3
4
Level 1 Investigation
Risk Management Plan
Assurance Plan
Assurance Plan
Communications Plan
Annual Plan
COMPETENCY ASSESSMENT
Assessors Name
Name of Person
Role of Person being Assessed
Reason for Assessment
Introduction of a new process, procedure or SOP
New Competency Requirement
Promotion
Competency Gap
Recruitment
Contributing factor in a non-conformance
Contributing factor in a Safety Event
Skill Atrophy
Skill Confirmation
Change Process
Competency Skill being Assessed from Framework
Please select
Option 1
Option 2
Option 3
Assessment Decision
Competent
Not Competent
Recommendations
General Comments
Training Plan
Plan Date
Employees Name
TRAINING PLAN
Training Need 1:
Training Requirement
Provider
Cost
Training Method
OJT
Mentoring / Coaching
Online Learning
External course
Internal course
Is More Training Required?
Yes
No
Training Need 2:
Training Requirement
Provider
Cost
Training Method
OJT
Mentoring / Coaching
Online Learning
External course
Internal course
Is More Training Required?
Yes
No
Training Need 3:
Training Requirement
Provider
Cost
Training Method
OJT
Mentoring / Coaching
Online Learning
External course
Internal course
Is More Training Required?
Yes
No
Training Need 4:
Training Requirement
Provider
Cost
Training Method
OJT
Mentoring / Coaching
Online Learning
External course
Internal course
Is More Training Required?
Yes
No
Training Need 5:
Training Requirement
Provider
Cost
Training Method
OJT
Mentoring / Coaching
Online Learning
External course
Internal course
Return To Work Rehabiltation Plan
Induction Form
Worker Details
Student Name
First
Last
Is the Person an Employee, Contractor or Other?
Employee
Contractor
Other
Contractors Parent Company
Parent Organisation
Date Induction Commenced
Induction Location
About KTD
Company Structure:
Yes
No
Key Persons:
Yes
No
The Workplace:
Yes
No
N/A
Introduction to Machinery Used:
Yes
No
N/A
Trainers Initials:
Workers Initials:
THE KTD MANAGEMENT SYSTEM
SAFETY MANAGEMENT
KTD Safety Policy
Yes
No
Worker Engagement
Yes
No
Risk Register
Yes
No
Safety Reporting Requirements
Yes
No
KTD Safety Obligations
Yes
No
Worker Safety Obligations
Yes
No
SOPS / SSoW
Yes
No
First Aiders:
Yes
No
Emergency Management:
Yes
No
Trainers Initials
Workers Initials
QUALITY MANAGEMENT
Quality Policy:
Yes
No
Quality Reporting Requirements:
Yes
No
Worker Quality Obligations:
Yes
No
Trainers Initials
Workers Initials
HUMAN RESOURCES
Employment Agreement:
Yes
No
Job Description:
Yes
No
Code of Conduct:
Yes
No
Bullying, Harassment and Discrimination Policy:
Yes
No
Other HR Policies:
Yes
No
Remuneration:
Yes
No
Competency Management:
Yes
No
Trainers Initials
Workers Initials
COMPETENCE ASSESSMENT
Competence Assessment Completed:
Yes
No
Training Plan has been Developed:
Yes
No
Trainers Initials
Workers Initials
Date Induction Completed:
HR Managers Name:
Email address
Please Select a Form
Safety Forms
Please select
Hazard Report
Safety Event Report
Equipment Commissioning
PPE Inspection
Contractor Selection
Safety Observation
PCBU Meeting Record
Vehicle Inspection
Competency Assessment
Date
Logged By
Please select
Jon-Brian Parker
Jim Pope
John Graumans
Carol
Christine
Hazard Title
Location
Please select
Zone 1
Zone 2
Zone 3
Hazard Description
Who could be harmed ?
What harm might occur ?
How might harm occur ?
Report Logged By:
Date Event Occurred
Safety Event Type
Please select
Near miss
Injury
Type of Near Miss
Please select
None of the following
Escape, Spillage or Leakage of a Substance
Implosion, Explosion or Fire
Escape of Gas or Steam
Escape of a Pressurised Substance
Electric Shock
Fall or Release from Height of any Plant Substance or Thing
The Collapse, Overturning, Failure, Malfunction of or Damage to any Plant required to be Authorised for use in accordance with regulations
Collapse of partial Collapse of a Structure
Collapse of Failure of an Excavation or Shoring of an Excavation
Inrush of Water, Mud or Gas in workings in an Underground Excavation of Tunnel
Interruption of the Main System of Ventilation in an Underground Excavation or Tunnel
A Collision between two vessels, vessel capsize or inrush of water into a Vessel
Name of Injured Person
Please select
Jon-Brian Parker
Jim Pope
John Graumans
Contractor
Carol
Christine
What injuries were sustained?
*
Provide a detailed description of what injuries were sustained and treatment provided.
Were the injuries any of the Following?
Please select
None of the following
A Serious Burn
An Injury requiring hospital treatment with in 48hrs of a substance
An Injury requiring immediate hospital treatment
The Lose of Bodily Function
A Serious Head Injury
A Serious Eye Injury
An Amputation
A Spinal Injury
An Illness requiring immediate hospital treatment
An Illness requiring hospital treatment within 48hrs of a substance
A Serious Infection
Death
Has The Scene Been Secured?
Yes
No
SECURE THE SCENE
Event Description
Provide a detailed description of what occurred and actions taken
Event Location
Please select
Zone 1
Zone 2
Zone 3
Witnesses' Name/s
List the names and contact details of all witnesses and those who were involved in the event.
Equipment Commissioning Checklist
Name of person Completing the Checklist:
Name of Item Being Commissioned
Description of Item Being Commissioned
Date Equipment Planned for Commissioning
HAS THE FOLLOWING BEEN COMPLETED:
AS/NZ 4024 Standard Met
Assessment against AS/NZ 4024 Completed
Yes
No
Date AS/NZ 4024 Assessment Completed
Maintenance Programme Prepared
Yes
No
Maintenance Programme Completed
Yes
No
Following Maintenance Documentation Provided:
Preventative Maintenance Plan
Electrical Certification
AS/NZ 4024 Certificate
Date Maintenance Programme Completed
Equipment Certified to AS/NZ 4024
Yes
No
Date Equipment Certified
HAS THE FOLLOWING DOCUMENTATION BEEN PREPARED:
Have SOPs / Safe Systems of Work
SOPs / SSoW Prepared
Yes
No
ACOP Requirement Met:
Yes
No
N/A
Date SOPs Completed
Training Requirements
Training Plan Prepared
Yes
No
Training Implemented
Yes
No
Date Training Completed
Risk Management
Risk Assessment Completed
Yes
No
Date Risk Assessment Completed
Risk Management Plan Prepared
Yes
No
Plan Not Required
Assurance Plan Prepared
Yes
No
Equipment Tested
Yes
No
Date Risk Management and Assurance Plans Completed
Commissioning Approval
All Requirements Satisfied
Yes
No
Date All Requirements Completed
Commissioning Approved
Yes
No
Date Commissioning Approved
Name of Person Approving Commissioning
Appointment of Person Approving Commissioning
Please fill in all fields to be able to Submit
SPI: Logged By
Please select
Jon-Brian Parker
Jim Pope
John Graumans
Carol
Christine
Name of Person
Please select
Jon-Brian Parker
Jim Pope
John Graumans
Contractor
Carol
Christine
SPI: Item Inspected
Please select
Boots
Eye Protection
SPI: Item Serial Number
SPI: Item State
SPI: Inspection Result
Please select
Passed
Failed
Recommendations
Date of next Inspection
Assessment Completed By:
Company Name
Date Application Received
Contract Work to be Undertaken / Services to be Provided
Name of Company Point of Contact
Have the Following Documents Been provided?
Safety Manual
Yes
No
Evidence of Worker Competence
Yes
No
Populated Risk Register
Yes
No
Documented SOPs / Safe Systems of Work / Procedures
Yes
No
Documented Emergency Procedures
Yes
No
Documented Emergency Procedures
Yes
No
Copy/s of Safety Committee Meetings
Yes
No
N/A
Copies of any JSAs /JSEAs / SSSPs
Yes
No
N/A
Evidence of Assurance Activities
Yes
No
N/A
Reporting Procedures
Safety Event Reporting Procedures Provided?
Yes
No
Hazard Reporting Procedures Provided?
Yes
No
Quality Management Reporting Procedures Provided?
Yes
No
Has the Company Issued PPE to their Workers?
Yes
No
Not Declared
Have The Following Insurance Certificates Been Provided?
Public Indemnity
Yes
No
N/A
Professional Indemnity
Yes
No
N/A
Vehicle
Yes
No
N/A
Statutory Indemnity
Yes
No
N/A
Prosecution Details
Has the Company ever been Prosecuted or does it have prosecutions pending by WorkSafe?
Yes
No
What are the Prosecution Details
Assessment Outcome
Approved
More Information Required
Not Approved
Date Assessment Completed
Comments
Training Plan
JSA Completed By:
Date
Job Location
Job Details
Safety Risk Tolerance Level
Very High
High
Medium
Low
Task Analysis
Task 1
Response Action
Eliminate
Minimise
Task Steps
Raw Risk Assessment
Very High
High
Medium
Low
Controls
Residual Risk Assessment
Very High
High
Medium
Low
Are There Any More Tasks?
Yes
No
Task 2
Response Action
Eliminate
Minimise
Task Steps
Raw Risk Assessment
Very High
High
Medium
Low
Controls
Residual Risk Assessment
Very High
High
Medium
Low
Are There Any More Tasks?
Yes
No
Task 3
Response Action
Eliminate
Minimise
Task Steps
Raw Risk Assessment
Very High
High
Medium
Low
Controls
Residual Risk Assessment
Very High
High
Medium
Low
Are There Any More Tasks?
Yes
No
Task 4
Response Action
Eliminate
Minimise
Task Steps
Raw Risk Assessment
Very High
High
Medium
Low
Controls
Residual Risk Assessment
Very High
High
Medium
Low
Are There Any More Tasks?
Yes
No
Task 5
Response Action
Eliminate
Minimise
Task Steps
Raw Risk Assessment
Very High
High
Medium
Low
Controls
Residual Risk Assessment
Very High
High
Medium
Low
Are There Any More Tasks?
Yes
No
Task 6
Response Action
Eliminate
Minimise
Task Steps
Raw Risk Assessment
Very High
High
Medium
Low
Controls
Residual Risk Assessment
Very High
High
Medium
Low
Are There Any More Tasks?
Yes
No
Task 7
Response Action
Eliminate
Minimise
Task Steps
Raw Risk Assessment
Very High
High
Medium
Low
Controls
Residual Risk Assessment
Very High
High
Medium
Low
Are There Any More Tasks?
Yes
No
Task 8
Response Action
Eliminate
Minimise
Task Steps
Raw Risk Assessment
Very High
High
Medium
Low
Controls
Residual Risk Assessment
Very High
High
Medium
Low
Are There Any More Tasks?
Yes
No
Task 9
Response Action
Eliminate
Minimise
Task Steps
Raw Risk Assessment
Very High
High
Medium
Low
Controls
Residual Risk Assessment
Very High
High
Medium
Low
Are There Any More Tasks?
Yes
No
Task 10
Response Action
Eliminate
Minimise
Task Steps
Raw Risk Assessment
Very High
High
Medium
Low
Controls
Residual Risk Assessment
Very High
High
Medium
Low
Workers Briefed:
Yes
No
Visitors Briefed:
Yes
No
Names of Workers Briefed
Supervisors Name
Safety Observation Report
Date of Observation
Person Making the Observation
Person Observed
Details of Observation
Was an Intervention Required?
Yes
No
Details of Intervention Taken
Are There Any Recommendations?
Yes
No
Recommendations
Enterprise
Attendee's
Location
Scope of work
Points of contact
KTD and other PCBU's
Responsibilities for safety
KTD and other PCBU's
Responsibilities for Quality
KTD and other PCBU's
Reporting Requirement's
KTD and other PCBU's
Induction Requirement's
KTD and other PCBU's
Worker Competence
KTD and other PCBU's
Dispute Resolution Process
KTD and other PCBU's
Assurance Activities'
KTD and other PCBU's
Risk Management
KTD and other PCBU's, Safety and Quality Risk's
Investigation's
Meeting Schedule
Process Procedure's for Common Use
Insurance Requirements
KTD and other PCBU
Emergency Management Requirements
KTD and other PCBU
General Matters
KTD and other PCBU
Logged By
Please select
Jon-Brian Parker
Jim Pope
John Graumans
Carol
Christine
Which Vehicle
Please select
VW Passet - KRR64
Hyundai i30 - HWL23
Ford Courier - HLY507
Tandem Trailer - S952Y
Nissan Forklift -
Hyster -
Milage
Fuel Type
Petrol
Diesel
Other
RUC
WOF Current
Yes
No
Date
Registration Current
Yes
No
Date
Windows'
Undamaged
Yes
No
Windows are Clean
Yes
No
Vehicle Panels are un damaged
Yes
No
Engine
Oil Level correct
Yes
No
Fan belt correctly tensioned and undamaged
Yes
No
Are there any Oil Leaks
Yes
No
Is Coolant level between Min - Max and coloured
Yes
No
Spare wheel is in place, inflated and in good repair
Yes
No
Wheel changing kit in place and complete
Yes
No
First Aid kit in place and complete
Yes
No
Fire Extinguisher in place and charged and not outside expiry date
Yes
No
Tyre Status
Correctly Inflated
Yes
No
Undamaged
Yes
No
More then minimum tread depth
Yes
No
Lights Status
Work on Full Beam
Yes
No
Work on Dip
Yes
No
Tail lights working
Yes
No
Brake lights working
Yes
No
Indicators working
Front - Yes
Front - No
Rear - Yes
Rear - No
Wiper Blades are in good repair
Yes
No
Wiper Blades are working
Yes
No
Reservoir is Full
Yes
No
Seat Belts Condition
Good
Damaged
Seat Belts Working
Yes
No
Interior Cleaning
Yes
No
Date of next Inspection
Competency Assessment
Assessors Name
Name of Person
Role of Person being Assessed
Reason for Assessment
Introduction of a new process, procedure or SOP
New Competency Requirement
Promotion
Competency Gap
Recruitment
Contributing factor in a non-conformance
Contributing factor in a Safety Event
Skill Atrophy
Skill Confirmation
Change Process
Competency Skill being Assessed from Framework
Please select
Option 1
Option 2
Option 3
Assessment Decision
Competent
Not Competent
Recommendations
General Comments
Email Address
*
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