Gravel Authorisation CRC____________
Site Specific Health and Safety Plan
Date:
1. Site summary
Work site:
Site Manager name
and contact details:
Site Specific Health and
Safety Plan written by:
Description of work:
Duration of work:
Name and Signature of
staff inducted on site:
Print name
Signature
Date
Print name
Signature
Date
Print name
Signature
Date
Print name
Signature
Date
Print name
Signature
Date
Print name
Signature
Date
Note: Processing material (crushing, screening) may classify the operation as a Quarry under Health and Safety Legislation. Make sure you can comply with the requirements of the legislation.
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2. Map of extraction area (include site access, any overhead or buried structures and other hazards).
N
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3. Site Specific Hazard Register: Fill in below any potentially significant hazards and how they will be controlled (a list of possible hazards can be
found below – this is not exhaustive)
HAZARD
CONTROL METHOD List control methods to eliminate, isolate or minimise the hazard
Machinery on steep banks
Moving machinery and moving parts on machinery
Excavated holes, soft ground, steep banks
Flooding of site
Other weather related possibilities: wind, rain, visibility,
temperature (hot/cold)
Trees fallen across access track
Public access
Traffic control
Overhead / buried wires or cables
Drowning
Stock in the river bed
List any other relevant hazards…
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4. Emergency contingency - medical
Nearest medical centre and contact details:
Emergency contact person and contact details:
Location of First Aid Kit on site
Contact for Fire, Ambulance and Police
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5. Emergency contingency – evacuation. Note this section should be updated on a weekly basis
Weather forecast for work period:
River flow conditions*:
Evacuation plan/route:
*Flow conditions can be found at: http://ecan.govt.nz/services/online-services/monitoring/river-flows/pages/default.aspx
Fire:
Accident:
 Try to extinguish or contain fire if practicable and
 Make the site safe
safe to do so
 Render assistance to the injured
 Contact emergency services
 Contact emergency services
 Contact Environment Canterbury – Gravel
o Give precise location
Authorisation officer to advise of incident
o Give details of the accident
 Be clear about how emergency services can access the site
 Remain in contact – cell or radio
 Worksafe may need to inspect, do not disturb the work site more than necessary to make it safe or to minimise environmental harm
 Contact Environment Canterbury – Gravel Authorisation officer to advise of incident
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6. Site check sheet:
 Health and Safety Plan read and understood
 Staff on site have signed page 1
 Hazard identification has been completed, controls developed and implemented – hazards are revisited each work day or more
frequently as required
 First Aid kit on site
 All people on site are wearing the appropriate Personal Protective Equipment for the job
 All people on site are competent for the tasks they are undertaking, or are under supervision of someone who is.
 Daily checks on communications – ensure cell coverage/radio coverage etc.
 Emergency contingency – flood evacuation plan, medical emergency
 Any visitors on site advised of site hazards and have signed visit sign in sheet.
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7. Signatory Page
Authorisation Holder:
 I confirm all staff and sub-contractors working on site will be fully inducted to site and into this Health and Safety Plan
 I confirm that all persons on site will be competent to complete assigned tasks or will be fully supervised by someone who is.
 I am aware of the hazards identified on this site and of my responsibilities to identify any additional hazards and take all practicable steps to eliminate,
isolate or minimise those hazards.
Signed by Authorisation Holder
7. Signatory Page
Date
Name
Authorisation Issuer:
I confirm I have reviewed this Health and Safety Plan and Site Specific Hazard Register and am satisfied that all practicable steps have been taken (or will be
taken immediately prior to commencement of work) and are appropriate.
Signed by Authorisation Issuer:
Date
Name
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Visitor sign in sheet
By signing this form I acknowledge that I have been advised of the site hazards by the site manager, I understand those hazards and will comply with all
hazard control measures and have read the Health and Safety Plan.
Name (print)
Date
Time In
Time Out
Signature
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