Site Specific Safety Plan - Site Safe

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2. Hazard Register PROJECT/SITE IDENTIFIED HAZARD POTENTIAL HARM SIGNIFICANT HAZARD E I M HAZARD CONTROLS REGULAR CHECK OF HAZARD CONTROLS IN PLACE Yes No Training Required Date Checked Date Checked Date Checked Date Checked October 2012 Page 7
Health and Safety in Employment Regulations 1995 3. Notification of Particular Hazardous Construction Work Please mail or fax this notification form to your nearest DoL branch. Sections 2 and 26 of the Health and Safety in Employment Regulations 1995 define Notifiable Work and set out who is responsible for making the notification. They are also quoted on the back of this form for your convenience. (If faxing this form, please return only the front page.) Notification is hereby given under the Health and Safety in Employment Regulations 1995 in respect of the following work: Nature of work (tick appropriate box): The erection or dismantling of scaffolding (all kinds) from which any person may fall 5 metres or more Buildings and structures where a fall of over 5 metres may occur Use of a lifting appliance to lift 500 kg or more a vertical distance of 5 metres or more Any narrow pit, shaft, trench or excavation more than 1.5 metres deep Drive, excavation or heading with ground cover overhead Excavated face over 5 metres deep with a face steeper than 63.4° (1 horizontal to 2 vertical) Storage or use of explosives Work in, or breathing of, compressed air or air substitute Restricted work involving asbestos (as defined in Regulation 2(1) of the Asbestos Regulations 1998) Demolition Tree felling in land clearance Tree felling in maintenance of overhead power lines Other: ...................................................................................................................................................................................... Address of worksite: .............................................................. Contractor Self-employed ............................................................................................... Business name: ......................................................................... …… ........................................................................................ Address: ..................................................................................... Main access road: ................................................................. ................................................................................................... Location: ................................................................................ Contact: ..................................................................................... ................................................................................................ Phone: .................................. Fax: ........................................ Principal/Employer: ............................................................... Certificate holder: ...................................................................... Address: ................................................................................. Certificate no.: ............................................................................ ............................................................................................... Phone: .................................. Fax: ........................................ (Please name certificate holder when notifying scaffolding, Contact: .................................................................................. diving, asbestos or use of explosives) Phone: ..................................... Fax: ................................... Brief description of work: ............................................................................................................................................................... ....................................................................................................................................................................................................... ................ ....................................................................................................................................................................................... Due date of commencement: ______/______/______ Estimated time to complete: ……………………………………… Date: ______/______/______ Signed: ……………………………………………………………… (For employer) DISCLAIMER: This form was correct as at November 2011. Please check www.osh.govt.nz for latest version. October 2012 Page 8
Page 2 and 3: A Safety Plan to Suit Your Job Cont
Page 4 and 5: Site Specific Safety Plan (SSSP) Ex
Page 6 and 7: 1. Site Specific Safety Plan Checkl
Page 10 and 11: Department of Labour phone: 0800 20
Page 12 and 13: 5. Task Analysis Worksheet JOB DESC
Page 14 and 15: 5a. Task Analysis Sign-off All pers
Page 16 and 17: 7. Pre-start Site Assessment PROJEC
Page 18 and 19: 8. Self Safety Inspection Checklist
Page 20 and 21: 9. Emergency Plan and Procedures fo
Page 22 and 23: 10. Accident/Incident Register PROJ
Page 24 and 25: 12. Accident and Incident Investiga
Page 26 and 27: 13. Safety Training and Competency
Page 28 and 29: 15. Site Specific Safety Plan Monit
Page 30 and 31: 16. Site Specific Safety Plan Evalu
Page 32 and 33: Definitions of Terms Definition of
Page 34 and 35: Site Safe Training to Assist You in
Page 36: Canterbury (covering Ashburton, Wes

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