Sale Order Number:



Customer Name:

Tasks being performed:

Yes No
Yes No
Yes No
Yes No

Have all applicable SWI/SWMS been reviewed prior to job task?

Are there any hazards that are not identified or covered by SWMS

Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

Equipment Used

Ladder

Yes No

Hand Tools

Yes No

Power Tools

Yes No

Other

Yes No

PPE required on site

Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

Can you undertake work safely?

Yes
No

Filled By: