Title: Job Safety Assessment

Site Name: Date:

What task is being performed today? Site survey （） Site
swap（）

Hazard Rating Associated Risk Control Measures

Electricity H M L

Working at
H M L
heights

Lifting of
material & H M L
equipment

Roadside
H M L
work

HV Testing H M L

Falling
H M L
objects

Moving
H M L
mobile plant

Slippery
H M L
surfaces

Moving
machinery H M L
parts

Explosion H M L

Sharp
H M L
objects

Hot objects H M L

Fire H M L

Weather
H M L
conditions

Snakes &
H M L
Bees

List
additional
hazards H M L
that were
identified
List
additional
hazards H M L
that were
identified

What PPE is required for this task?

Overall Pants Reflective Dust coat Apron Hard hat Gum Safety Safety Face Welding Dust mask Respirator Ear Safety belt Gloves Shoe spats
Title: Job Safety Assessment

jacket boots shoes Glasses shield helmet protection (harness)

Acknowledgement:

I acknowledge that I am conversant with the work instructions as listed in this risk assessment. I also understand the
risks associated with the task that I am going to perform. I further undertake to work according to the work
instructions and risk assessment that was discussed with me and that I will report any unsafe conditions that I
discover while I am working.

Name Signature Name Signature

This form must be uploaded to EPMS or iCneter group

Team Leader Signature: __________________________ Date: _______________