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Take 5 Assessment

Fill out form below

Is this for an indivual student or a group(Required)

Student

Group

Student's first and last name or Group Name(Required)

Location

Other Location

Date

DD slash MM slash YYYY

Job Task

STOP AND THINK THROUGH THE TASK

1. Is there a procedure for this task (SWMS/JSA/JHA/SOP/SWP)(Required)

Yes

No

NA

2. Is there a change to a process, procedure, or design?(Required)

Yes

No

NA

3. Do I have the required permits (e.g., hot work/heights/confined space)?(Required)

Yes

No

NA

4. Am I trained, competent and authorised for this task?(Required)

Yes

No

NA

5. Do I have a clear plan in mind?(Required)

Yes

No

NA

6. Do I have the correct personal protective equipment?(Required)

Yes

No

NA

IDENTIFY THE HAZARDS

1. Do I have to isolate to control sources of energy?(Required)

Yes

No

NA

2. Am I fit to perform this task (aware, rested, alert)?(Required)

Yes

No

NA

3. Could current weather/environmental conditions affect this task?(Required)

Yes

No

NA

Q3. Describe the Hazard

Q3. List the Controls to Reduce the Hazard

4. Could this task introduce hazards to others or damage equipment?(Required)

Yes

No

NA

Q4. Describe the Hazard

Q4. List the Controls to Reduce the Hazard

5. Could this task impact the environment or cultural heritage?(Required)

Yes

No

NA

6. Is the work area neat and tidy (clear access and egress)?

Yes

No

NA

7. Can I slip, trip or fall?(Required)

Yes

No

NA

Q7. Describe the Hazard

Q7. List the Controls to Reduce the Hazard

8. Can I strain or over-exert myself?(Required)

Yes

No

NA

Q8. Describe the Hazard

Q8. List the Controls to Reduce the Hazard

9. Can I be caught in, on, or between anything?(Required)

Yes

No

NA

Q9. Describe the Hazard

Q9. List the Controls to Reduce the Hazard

10. Can something fall on or strike me or others?(Required)

Yes

No

NA

Q10. Describe the Hazard

Q10. List the Controls to Reduce the Hazard

11. Have I looked close, wide, above and below the task area?(Required)

Yes

No

NA

12. Do I need help to do this task?(Required)

Yes

No

NA

13. Do I understand the directions given by my supervisor/the procedure?(Required)

Yes

No

NA

14. Are there any other hazards associated with this task?(Required)

Yes

No

NA

Q14. Describe the Hazard

Q14. List the Controls to Reduce the Hazard

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Q3.

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Q4.

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Q7.

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Q8.

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Q9.

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Q10.

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Q14.

Home
Main Site
Partner Info
Backpacker
Forms
About Us
Contact Us

Address: 8 Spoto Street, Woree QLD 486

Phone: 0407 471 817

Email: info@cairnstruckschool.com

ABN: 93 151 817 284