Take 5 Job Safety Form


This form must be completed PRIOR to commencing any works on behalf of Active Utilities.


Active Utilities values the safety of its staff and contractors. You must take responsibility for your actions and ensure a clean and safe work environment prior to commencing and during any works. If you are unsure, not comfortable or require assistance, materials or equipment, you MUST ensure to contact your supervisor or Active delegate to discuss. Safety first at all times, not exceptions or excuses.


If you answer No to any item below YOU MUST NOT START WORKS until all items are resolved. Contact your supervisor or Active delegate for direction.

 

Job reference number provided by Active Utilities

 

Project or Job name provided by Active Utilities

 

Your full name

 

Name of Contractor Supervisor

 

Email address of Contractor Supervisor

 

Name of your supervisor for this job

 

Specify what works are required to be completed at this attendance.

 

Are you appropriately trained / qualified to complete this task?

 

Do you have sufficient resourcing and or supervision to complete task?

 
 
 

Have you completed any required inductions for this site?

 
 

Have you ensured to notify others that may be impacted by your works prior to commencing?

 

Do you have the appropriate safety wear and equipment to complete this task?

 
 
 
 
 
 

Please confirm if the job is safe to proceed. If not, do not start works and contact your supervisor or Active Utilities Delegate immediately.