Xacom Contractor Take5

Fill in the details to complete your Take5 before commencing works on-site.

Subject

Name

Company

Phone Number

Job Site

Location

Is my supervisor aware of what task I am about to do? *

If no is selected, notify your supervisor immediately. Describe the problem & issue. DO NOT COMMENCE WORK UNTIL YOU TALK TO YOUR SUPERVISOR.

Are you working alone? *

Is it safe to work alone? *

Am I authorized to perform the job? *

Do I feel comfortable about the task at hand? *

Am I physically able to do the Task? *

Do I have the correct tools or equipment for the job? *

Do I have the correct PPE for the Task? *

Are the conditions suitable to do the Task? *

Have I discussed the Task with others in the work area? *

Is the work area clear of all hazards? *

Energy sources ID'ed, isolated, locked out & tagged? *

Network Related - Have you advised the relevant IT Dept *

Are you referencing a JSA, JSEA, SWMS or SWP? *

Reference Code *

JSA, JSEA, SWMS or SWP Reference Code

Witnessed or Objected to Harassment? *

If driving on site, are the conditions safe? *

Look for hazards

ATMOSPHERIC (Weather, Dust, Gases, Oxygen) *

BIOLOGICAL (Bacteria/viruses/pests/ plants/birds/animals *

CHEMICAL (Acids/Bases/Solvents/ Fumes/Vapors/Poisons) *

ELECTRICAL (Electrocution/Faulty Wiring/Earthing/Static) *

ENVIRONMENTAL (Confined Space/Lighting/Noises/ Cold/HVAC) *

EXTERNAL (traffic/other workers/general public.) *

FIRE/EXPLOSIONS (Flames/Combustibles/ Arching/Chem Reactions) *

GRAVITATIONAL (Falls/slips/trips/falling objects) *

MANUAL HANDLING (Lifting/Pulling/Pushing/ Twisting/Awkward) *

MECHANICAL (Impacts/Entangle/ Stabbing/Crushing/Suction) *

PRESSURE (Air/water/oil/gas/ vacuums/high or low pressures) *

THERMAL (Hot cold surfaces/hot cold liquids/steam/friction) *

Have you been inducted to site *

Upload Images

Maximum 5 Files

Submit