Health, Safety and Environment
HSEF0912.1 – Heritage Impact Assessment Long Form
Approved by: WHS & HSE Systems Manager
Revision: 2
Date: Jun 2015
Page 1 of 4
Form variations to suit user, system / software constraints, legal requirements or corporate requirements are permissible, as
long as the intent of the form is not compromised.
<Title of the Works>
Heritage Impact Assessment prepared by:
<Name & Qualifications of Person Preparing the HIA>
<Position Held>
<Name of Business>
<Address>
<Phone Number>
Date prepared: <insert date>
Revision No.:
<insert rev. no.>
Signature:
................................................................
Accepted by:
HT <Project Title> Project Manager
....................................................
Comments: ........................................................................ <insert Project Manager's name>
............................................................................................
............................................................................................
Date: <insert date>
Revision No.: <insert rev. no.>
Authorised by:
HT Sustainable Resources Manager
....................................................
Comments: ........................................................................ <insert Sust Resources Mgr's name>
............................................................................................
............................................................................................
Date: <insert date>
Revision No.: <insert rev. no.>
Approved by:
HT Production Manager
........................................................................
Comments: ........................................................................ <insert Production Mgr's Name>
............................................................................................
............................................................................................
CAUTION: Printed Document is UnControlled
Heritage Impact Assessment
Date: <insert date>
Revision No.: <insert rev. no.>
Print Date: 16/02/2016
Health, Safety and Environment
HSEF0912.1 – Heritage Impact Assessment Long Form
Approved by: WHS & HSE Systems Manager
Revision: 2
Date: Jun 2015
Page 2 of 4
Form variations to suit user, system / software constraints, legal requirements or corporate requirements are permissible, as
long as the intent of the form is not compromised.
Description of Works
Background
<insert background>
Heritage Impact Assessment
The following table/s set/s out the various Works covered in this Assessment with a
description of the Works to be undertaken and an Assessment of the potential Impact.
Recommendations are set out at the end of the Assessment.
<Note that if the scope of Works changes then a revised or new Heritage Impact
Assessment will be required.>
CAUTION: Printed Document is UnControlled
Heritage Impact Assessment
Print Date: 16/02/2016
Health, Safety and Environment
HSEF0F0912.1 – Heritage Impact Assessment Long Form
Approved by: WHS & HSE Systems Manager
Revision: 2
Date: Jun 2015
Page 3 of 4
Form variations to suit user, system / software constraints, legal requirements or corporate requirements are permissible, as long as the intent of the form is not compromised.
1. <Title of Works> (This should relate to one feature with all Works described in the proposed Works in groups. Refer here to any
figures/sheets/principle project requirements etc.)
Proposed Works
(This section should include all Works proposed and any alternatives
Key Attributes Summary
(Describe here any details of significant components such as original features)
Primary Reference/s:
(Describe here any key documents such as Conservation Management Plans (CMP))
Site Feature
and Location
(insert
Inventory
Datasheet or
location of
feature in
CMP)
Significance Rating &
CMP Guideline/s
(insert Significance
Rating and
recommendations
from Datasheet or
CMP
recommendations)
Heritage Impact
(describe the Impact on the
Heritage Values of the Site. Also
discuss any Impacts on Sites of
Low or Medium Heritage Impact.)
Required Management/
Mitigation Measures
(describe any Mitigation or
descriptions of management
approaches that limit or restrict
the Works.)
Advice to ensure quality/compliance
(include information that would be of
use during a Heritage Audit of the Works
e.g. what needs to be prepared for
Mitigation and by whom.)
2. Recommendations (To be completed by HT Cultural Heritage Program Workers or Environmental and Heritage Manager)
1.
2.
CAUTION: Printed Document is UnControlled
Heritage Impact Assessment
Print Date: 16/02/2016
Health, Safety and Environment
HSEF0F0912.1 – Heritage Impact Assessment Long Form
Approved by: WHS & HSE Systems Manager
Revision: 2
Date: Jun 2015
Page 4 of 4
Form variations to suit user, system / software constraints, legal requirements or corporate requirements are permissible, as long as the intent of the form is not compromised.
3. RELEVANT DRAWINGS & PHOTOGRAPHS/ATTACHMENTS
CAUTION: Printed Document is UnControlled
Heritage Impact Assessment
Print Date: 16/02/2016