Site Specific Safety Plan pdf version - 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 December 2013 Page 7
Health and Safety in Employment Regulations 1995 3. Notification of Particular Hazardous Construction Work Please mail or fax this form to: The Registrar, Health and Safety Group Response Team, PO Box 105146, Auckland, Email HealthSafety.Notification@dol.govt.nz, Fax: 09 984 4115. Regulations 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): Scaffolding (all kinds). Buildings and structures over 5 metres. Use of a lifting appliance. Trench, shaft, pit, etc. Drive or heading. Excavated face over 5 metres. Use of explosives, Work in, or breathing, compressed air or air substitute Restricted work involving asbestos. Demolition. Felling trees for logging. Tree felling for commercial firewood. Tree felling in land clearance. Tree felling in maintenance of horticulture shelterbelts. Tree felling in maintenance of overhead power lines Tree felling in arboriculture. Tree felling in silviculture. Tree felling for willow layering and other work in catchment areas. Tree felling involving wind throw. 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 December 2013. Check www.worksafe.govt.nz for latest version. After 16 December 2013, notify the WorkSafe New Zealand Health and Safety Group Central Response Team: - Call 0800 20 90 20 - Go to www.worksafe.govt.nz - Email healthsafety.notification@dol.govt.nz December 2013 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: WorkSafe New Zealand 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

Site Specific Safety Plan pdf version - Site Safe

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