SLATER ACTIONS SYSTEM

Please Select One of the Following:

Safety Forms

Product Forms

Logged By

Hazard Title

Location

Hazard Description

Who could be harmed ?

What harm might occur ?

How might harm occur ?

Report Logged By:

Date Event Occurred

Safety Event Type

Type of Near Miss

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 Following?

Has The Scene Been Secured?

Yes

SECURE THE SCENE

Event Description

Provide a detailed description of what occurred and actions taken

Event Location

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

Date AS/NZ 4024 Assessment Completed

Maintenance Programme Prepared

Yes

Maintenance Programme Completed

Yes

Following Maintenance Documentation Provided:

Preventative Maintenance Plan

Electrical Certification

AS/NZ 4024 Certificate

Date Maintenance Programme Completed

Equipment Certified to AS/NZ 4024

Yes

Date Equipment Certified

HAS THE FOLLOWING DOCUMENTATION BEEN PREPARED:

Have SOPs / Safe Systems of Work

SOPs / SSoW Prepared

Yes

ACOP Requirement Met:

Yes

N/A

Date SOPs Completed

Training Requirements

Training Plan Prepared

Yes

Training Implemented

Yes

Date Training Completed

Risk Management

Risk Assessment Completed

Yes

Date Risk Assessment Completed

Risk Management Plan Prepared

Yes

Plan Not Required

Assurance Plan Prepared

Yes

Equipment Tested

Yes

Date Risk Management and Assurance Plans Completed

Commissioning Approval

All Requirements Satisfied

Yes

Date All Requirements Completed

Commissioning Approved

Yes

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

Name of Person

Item Inspected

Item Serial Number

Item State

Inspection Result

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

Evidence of Worker Competence

Yes

Populated Risk Register

Yes

Documented SOPs / Safe Systems of Work / Procedures

Yes

Documented Emergency Procedures

Yes

Documented Emergency Procedures

Yes

Copy/s of Safety Committee Meetings

Yes

N/A

Copies of any JSAs /JSEAs / SSSPs

Yes

N/A

Evidence of Assurance Activities

Yes

N/A

Reporting Procedures

Safety Event Reporting Procedures Provided?

Yes

Hazard Reporting Procedures Provided?

Yes

Quality Management Reporting Procedures Provided?

Yes

Has the Company Issued PPE to their Workers?

Yes

Not Declared

Have The Following Insurance Certificates Been Provided?

Public Indemnity

Yes

N/A

Professional Indemnity

Yes

N/A

Vehicle

Yes

N/A

Statutory Indemnity

Yes

N/A

Prosecution Details

Has the Company ever been Prosecuted or does it have prosecutions pending by WorkSafe?

Yes

What are the Prosecution Details

Assessment Outcome

Approved

More Information Required

Not Approved

Date Assessment Completed

Comments

Job Safety Analysis

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

Raw Risk - Likelihood Assessment

Rare

Unlikely

Possible

Likely

Almost Certain

Raw Risk - Impact Assessment

Not Significant

Minor

Moderate

Major

Severe

The raw risk assessment is: LOW

The raw risk assessment is: MEDIUM

The raw risk assessment is: LOW

The raw risk assessment is: MEDIUM

The raw risk assessment is: HIGH

The raw risk assessment is: VERY HIGH

The raw risk assessment is: MEDIUM

Controls

RESIDUAL RISK ASSESSMENT

Residual Risk - Likelihood Assessment

Rare

Unlikely

Possible

Likely

Almost Certain

Residual Risk - Impact Assessment

Not Significant

Minor

Moderate

Major

Severe

The residual risk assessment is: LOW

The residual risk assessment is: MEDIUM

The residual risk assessment is: LOW

The residual risk assessment is: MEDIUM

The residual risk assessment is: HIGH

The residual risk assessment is: VERY HIGH

The residual risk assessment is: MEDIUM

Are There Any More Tasks?

Yes

Task 2

Response Action

Eliminate

Minimise

Task Steps

RAW RISK ASSESSMENT

Raw Risk - Likelihood Assessment

Rare

Unlikely

Possible

Likely

Almost Certain

Raw Risk - Impact Assessment

Not Significant

Minor

Moderate

Major

Severe

The raw risk assessment is: LOW

The raw risk assessment is: MEDIUM

The raw risk assessment is: LOW

The raw risk assessment is: MEDIUM

The raw risk assessment is: HIGH

The raw risk assessment is: VERY HIGH

The raw risk assessment is: MEDIUM

Controls

RESIDUAL RISK ASSESSMENT

Residual Risk - Likelihood Assessment

Rare

Unlikely

Possible

Likely

Almost Certain

Residual Risk - Impact Assessment

Not Significant

Minor

Moderate

Major

Severe

The residual risk assessment is: LOW

The residual risk assessment is: MEDIUM

The residual risk assessment is: LOW

The residual risk assessment is: MEDIUM

The residual risk assessment is: HIGH

The residual risk assessment is: VERY HIGH

The residual risk assessment is: MEDIUM

Are There Any More Tasks?

Yes

Task 3

Response Action

Eliminate

Minimise

Task Steps

RAW RISK ASSESSMENT

Raw Risk - Likelihood Assessment

Rare

Unlikely

Possible

Likely

Almost Certain

Raw Risk - Impact Assessment

Not Significant

Minor

Moderate

Major

Severe

The raw risk assessment is: LOW

The raw risk assessment is: MEDIUM

The raw risk assessment is: LOW

The raw risk assessment is: MEDIUM

The raw risk assessment is: HIGH

The raw risk assessment is: VERY HIGH

The raw risk assessment is: MEDIUM

Controls

RESIDUAL RISK ASSESSMENT

Residual Risk - Likelihood Assessment

Rare

Unlikely

Possible

Likely

Almost Certain

Residual Risk - Impact Assessment

Not Significant

Minor

Moderate

Major

Severe

The residual risk assessment is: LOW

The residual risk assessment is: MEDIUM

The residual risk assessment is: LOW

The residual risk assessment is: MEDIUM

The residual risk assessment is: HIGH

The residual risk assessment is: VERY HIGH

The residual risk assessment is: MEDIUM

Are There Any More Tasks?

Yes

Task 4

Response Action

Eliminate

Minimise

Task Steps

RAW RISK ASSESSMENT

Raw Risk - Likelihood Assessment

Rare

Unlikely

Possible

Likely

Almost Certain

Raw Risk - Impact Assessment

Not Significant

Minor

Moderate

Major

Severe

The raw risk assessment is: LOW

The raw risk assessment is: MEDIUM

The raw risk assessment is: LOW

The raw risk assessment is: MEDIUM

The raw risk assessment is: HIGH

The raw risk assessment is: VERY HIGH

The raw risk assessment is: MEDIUM

Controls

RESIDUAL RISK ASSESSMENT

Residual Risk - Likelihood Assessment

Rare

Unlikely

Possible

Likely

Almost Certain

Residual Risk - Impact Assessment

Not Significant

Minor

Moderate

Major

Severe

The residual risk assessment is: LOW

The residual risk assessment is: MEDIUM

The residual risk assessment is: LOW

The residual risk assessment is: MEDIUM

The residual risk assessment is: HIGH

The residual risk assessment is: VERY HIGH

The residual risk assessment is: MEDIUM

Are There Any More Tasks?

Yes

Task 5

Response Action

Eliminate

Minimise

Task Steps

RAW RISK ASSESSMENT

Raw Risk - Likelihood Assessment

Rare

Unlikely

Possible

Likely

Almost Certain

Raw Risk - Impact Assessment

Not Significant

Minor

Moderate

Major

Severe

The raw risk assessment is: LOW

The raw risk assessment is: MEDIUM

The raw risk assessment is: LOW

The raw risk assessment is: MEDIUM

The raw risk assessment is: HIGH

The raw risk assessment is: VERY HIGH

The raw risk assessment is: MEDIUM

Controls

RESIDUAL RISK ASSESSMENT

Residual Risk - Likelihood Assessment

Rare

Unlikely

Possible

Likely

Almost Certain

Residual Risk - Impact Assessment

Not Significant

Minor

Moderate

Major

Severe

The residual risk assessment is: LOW

The residual risk assessment is: MEDIUM

The residual risk assessment is: LOW

The residual risk assessment is: MEDIUM

The residual risk assessment is: HIGH

The residual risk assessment is: VERY HIGH

The residual risk assessment is: MEDIUM

Are There Any More Tasks?

Yes

Task 6

Response Action

Eliminate

Minimise

Task Steps

RAW RISK ASSESSMENT

Raw Risk - Likelihood Assessment

Rare

Unlikely

Possible

Likely

Almost Certain

Raw Risk - Impact Assessment

Not Significant

Minor

Moderate

Major

Severe

The raw risk assessment is: LOW

The raw risk assessment is: MEDIUM

The raw risk assessment is: LOW

The raw risk assessment is: MEDIUM

The raw risk assessment is: HIGH

The raw risk assessment is: VERY HIGH

The raw risk assessment is: MEDIUM

Controls

RESIDUAL RISK ASSESSMENT

Residual Risk - Likelihood Assessment

Rare

Unlikely

Possible

Likely

Almost Certain

Residual Risk - Impact Assessment

Not Significant

Minor

Moderate

Major

Severe

The residual risk assessment is: LOW

The residual risk assessment is: MEDIUM

The residual risk assessment is: LOW

The residual risk assessment is: MEDIUM

The residual risk assessment is: HIGH

The residual risk assessment is: VERY HIGH

The residual risk assessment is: MEDIUM

Are There Any More Tasks?

Yes

Task 7

Response Action

Eliminate

Minimise

Task Steps

RAW RISK ASSESSMENT

Raw Risk - Likelihood Assessment

Rare

Unlikely

Possible

Likely

Almost Certain

Raw Risk - Impact Assessment

Not Significant

Minor

Moderate

Major

Severe

The raw risk assessment is: LOW

The raw risk assessment is: MEDIUM

The raw risk assessment is: LOW

The raw risk assessment is: MEDIUM

The raw risk assessment is: HIGH

The raw risk assessment is: VERY HIGH

The raw risk assessment is: MEDIUM

Controls

RESIDUAL RISK ASSESSMENT

Residual Risk - Likelihood Assessment

Rare

Unlikely

Possible

Likely

Almost Certain

Residual Risk - Impact Assessment

Not Significant

Minor

Moderate

Major

Severe

The residual risk assessment is: LOW

The residual risk assessment is: MEDIUM

The residual risk assessment is: LOW

The residual risk assessment is: MEDIUM

The residual risk assessment is: HIGH

The residual risk assessment is: VERY HIGH

The residual risk assessment is: MEDIUM

Are There Any More Tasks?

Yes

Task 8

Response Action

Eliminate

Minimise

Task Steps

RAW RISK ASSESSMENT

Raw Risk - Likelihood Assessment

Rare

Unlikely

Possible

Likely

Almost Certain

Raw Risk - Impact Assessment

Not Significant

Minor

Moderate

Major

Severe

The raw risk assessment is: LOW

The raw risk assessment is: MEDIUM

The raw risk assessment is: LOW

The raw risk assessment is: MEDIUM

The raw risk assessment is: HIGH

The raw risk assessment is: VERY HIGH

The raw risk assessment is: MEDIUM

Controls

RESIDUAL RISK ASSESSMENT

Residual Risk - Likelihood Assessment

Rare

Unlikely

Possible

Likely

Almost Certain

Residual Risk - Impact Assessment

Not Significant

Minor

Moderate

Major

Severe

The residual risk assessment is: LOW

The residual risk assessment is: MEDIUM

The residual risk assessment is: LOW

The residual risk assessment is: MEDIUM

The residual risk assessment is: HIGH

The residual risk assessment is: VERY HIGH

The residual risk assessment is: MEDIUM

Are There Any More Tasks?

Yes

Task 9

Response Action

Eliminate

Minimise

Task Steps

RAW RISK ASSESSMENT

Raw Risk - Likelihood Assessment

Rare

Unlikely

Possible

Likely

Almost Certain

Raw Risk - Impact Assessment

Not Significant

Minor

Moderate

Major

Severe

The raw risk assessment is: LOW

The raw risk assessment is: MEDIUM

The raw risk assessment is: LOW

The raw risk assessment is: MEDIUM

The raw risk assessment is: HIGH

The raw risk assessment is: VERY HIGH

The raw risk assessment is: MEDIUM

Controls

RESIDUAL RISK ASSESSMENT

Residual Risk - Likelihood Assessment

Rare

Unlikely

Possible

Likely

Almost Certain

Residual Risk - Impact Assessment

Not Significant

Minor

Moderate

Major

Severe

The residual risk assessment is: LOW

The residual risk assessment is: MEDIUM

The residual risk assessment is: LOW

The residual risk assessment is: MEDIUM

The residual risk assessment is: HIGH

The residual risk assessment is: VERY HIGH

The residual risk assessment is: MEDIUM

Are There Any More Tasks?

Yes

Task 10

Response Action

Eliminate

Minimise

Task Steps

RAW RISK ASSESSMENT

Raw Risk - Likelihood Assessment

Rare

Unlikely

Possible

Likely

Almost Certain

Raw Risk - Impact Assessment

Not Significant

Minor

Moderate

Major

Severe

The raw risk assessment is: LOW

The raw risk assessment is: MEDIUM

The raw risk assessment is: LOW

The raw risk assessment is: MEDIUM

The raw risk assessment is: HIGH

The raw risk assessment is: VERY HIGH

The raw risk assessment is: MEDIUM

Controls

RESIDUAL RISK ASSESSMENT

Residual Risk - Likelihood Assessment

Rare

Unlikely

Possible

Likely

Almost Certain

Residual Risk - Impact Assessment

Not Significant

Minor

Moderate

Major

Severe

The residual risk assessment is: LOW

The residual risk assessment is: MEDIUM

The residual risk assessment is: LOW

The residual risk assessment is: MEDIUM

The residual risk assessment is: HIGH

The residual risk assessment is: VERY HIGH

The residual risk assessment is: MEDIUM

Workers Briefed:

Yes

Names of Workers Briefed

Visitors Briefed:

Yes

Names of Visitors Briefed

Supervisors Name

Safety Observation Report

Date of Observation

Person Making the Observation

Person Observed

Details of Observation

Was an Intervention Required?

Yes

Details of Intervention Taken

Are There Any Recommendations?

Yes

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

Which Vehicle

Milage

Fuel Type

Petrol

Diesel

Other

RUC

WOF Current

Yes

Date

Registration Current

Yes

Date

Windows'

Undamaged

Yes

Windows are Clean

Yes

Vehicle Panels are un damaged

Yes

Engine

Oil Level correct

Yes

Fan belt correctly tensioned and undamaged

Yes

Are there any Oil Leaks

Yes

Is Coolant level between Min - Max and coloured

Yes

Spare wheel is in place, inflated and in good repair

Yes

Wheel changing kit in place and complete

Yes

First Aid kit in place and complete

Yes

Fire Extinguisher in place and charged and not outside expiry date

Yes

Tyre Status

Correctly Inflated

Yes

Undamaged

Yes

More then minimum tread depth

Yes

Lights Status

Work on Full Beam

Yes

Work on Dip

Yes

Tail lights working

Yes

Brake lights working

Yes

Indicators working

Front - Yes

Front - No

Rear - Yes

Rear - No

Wiper Blades are in good repair

Yes

Wiper Blades are working

Yes

Reservoir is Full

Yes

Seat Belts Condition

Good

Damaged

Seat Belts Working

Yes

Interior Cleaning

Yes

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

Assessment Decision

Competent

Not Competent

Recommendations

General Comments

Date

Risk Perspective

HAZARD INFORMATION

Hazard Title

Hazard Desciption

A detailed description of the hazard.

Who could Be Harmed?

What Harm might Occur?

A detailed description of how someone might get hurt.

How Might Harm Occur?

A detailed description of how the hazard may cause the harm.

Hazard Location

ISSUE INFORMATION

Issue Title

Issue Description

A detailed description of the issue and the risk it presents.

Effect of the Issue

A description of the effects to the business should the risk materialise.

RISK RESPONSE

Threat or Opportunity

Threat

Opportunity

Safety Response

Eliminate

Minimise

Threat Response

Avoid

Reduce

Opportunity

Exploit

Enhance

Reject

EFFECTIVENESS OF CURRENT CONTROLS

Control 1

Control 1 Effectiveness

Fully Effective

Partially Effective

Not Effective

Control 2

Control 2 Effectiveness

Fully Effective

Partially Effective

Not Effective

Control 3

Control 3 Effectiveness

Fully Effective

Partially Effective

Not Effective

Control 4

Control 4 Effectiveness

Fully Effective

Partially Effective

Not Effective

Control 5

Control 5 Effectiveness

Fully Effective

Partially Effective

Not Effective

Control 6

Control 6 Effectiveness

Fully Effective

Partially Effective

Not Effective

Control 7 Effectiveness

Fully Effective

Partially Effective

Not Effective

Control 7

Control 8

Control 8 Effectiveness

Fully Effective

Partially Effective

Not Effective

Control 9

Control 9 Effectiveness

Fully Effective

Partially Effective

Not Effective

Control 10

Control 10 Effectiveness

Fully Effective

Partially Effective

Not Effective

RISK FACTORS

List and explain all the factors that affect and determine the likelihood and impact of the harm or issue.

RAW RISK ASSESSMENT

Raw Risk - Likelihood Assessment

Almost Certain

Likely

Possible

Unlikely

Rare

Raw Risk - Impact Assessment

Severe

Major

Moderate

Minor

Not Significant

The raw risk assessment is: LOW

The raw risk assessment is: MEDIUM

The raw risk assessment is: HIGH

The raw risk assessment is: VERY HIGH

CONTROLS

Changes To Current Controls

New Controls

RESIDUAL RISK ASSESSMENT

Residual Risk - Likelihood Assessment

Almost Certain

Likely

Possible

Unlikely

Rare

Residual Risk - Impact Assessment

Severe

Major

Moderate

Minor

Not Significant

The residual risk assessment is: LOW

The residual risk assessment is: MEDIUM

The residual risk assessment is: HIGH

The residual risk assessment is: VERY HIGH

Risk Accepted?

Yes

Management Priority

Gutter Clean Estimate

Is Access:

Easy

Restricted

Is the Building:

Single Story

Multi Story

Is the Roof Surface Area:

100 sqm or less

100 - 200 sqm

200+ sqm

Is Water Supply:

Tank

Town Supply

The estimated cost to clean your guttering would be $300

The estimated cost to clean your guttering would be $1000

Date

Email Address*

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