This form is designed to assist you in setting up safely for the work you are about to undertake and provides a list of hazards that may be present on your worksite.
You should always Eliminate (E) the risk of a hazard causing death, injury, or illness if you can. Where this is not possible, you must Minimise (M) the risk. There may be occasions where multiple controls are appropriate.
Enter your work method in the space provided below then use this checklist to identify any associated hazard/s. Brief everyone involved in the work being undertaken, ensure the appropriate controls are in place to control the risk/s, sign the form and submit as part of your job documentation.
Please contact HazardCo on 0800 555 339 if you require any assistance to identify hazards or implement the required controls.
Company:
TA Completed By:
Contact Cell Ph:
Site Address/Ref:
Date:
Task Description:
Ref Document:
Approved Code Of Practice For Safety in excavation and shafts for foundations – Published Sep 1995 by the Occupational Safety and
Health Service Department of Labour. Reprinted April 2000.
At Base
1. HazardCo Team Pack is in vehicle.
2. Vehicle has a current WOF/COF, lights and tyres in working condition.
3. Minimum PPE/PPC available and in good condition.
4. All emergency equipment and materials required for the work being undertaken loaded and secured.
5. All work documents for job in vehicle.
Yes No At Site
❑ ❑ 1. Park in a safe place.
❑ ❑ 2. Ensure you wear your PPE/PPC and it is in good condition and appropriate for the work to be undertaken i.e. overalls, boots, mask, gloves, eye, hearing and dust protection.
❑ ❑ 3. HazardCo Hazard Board set up in the vicinity of where work is being undertaken.
❑ ❑ 4. Ensure you are inducted onto site - liaise with any Site Manager/Contractor/Client present to establish exactly what they are doing on site and any hazards associated with their work. Conduct your own induction if alone on site. Ensure the Hazard
Board is updated and Emergency Plan is complete.
❑ ❑ 5. Explain to Site Manager/Contractor/Client any hazards you are bringing to site or that may be present as a result of your work (use HazardCo Client Induction Cards where appropriate).
Yes No
❑ ❑
❑ ❑
❑ ❑
❑ ❑
❑ ❑
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Describe how you plan to carry out the work, using the example shown in the left hand column as a guide. Write your own method in the Work Method column on the right.
Work Method Example
1. On Arrival complete Job Start Checklist on Task Analysis
2. Complete / Review Task Analysis questionnaire and brief all workers on hazards and required risk controls
– sign off form.
3. Warning and safety signage in place
4. Check for overhead and underground services, adjacent structures, and other site hazards (dial before you dig)
5. Set up site fencing/barriers around work area
Our Work Method
6. Unload equipment and all required materials
7. Check all equipment is in good working order and safe for use
8. Complete pre-start checks on any machinery to be used
9. Set up an Operational Safety Zone including set down area for any removed material
10. Excavate trench
11. Carry out required task
12. Back fill excavation
13. Ensure back filling is level and secure
14. Clean machinery and equipment
15. Tidy up / depart site
Page 2 of 9

Answer the following questions relevant to the task you are doing ( Tick “Yes” or “No”)
Yes No
Hazard Identified
1. Will you use any subcontractors?
❑ ❑
Visitors/Contractors
2. Is the job in a residential area or near a school ?
❑ ❑
Injury to public
(residential area)
3. Will a toilet be available and is there running water on site?
❑ ❑
Illness/Disease
4. Will there be any vehicles coming on to site?
5. Are any electrical appliances to be used?
❑ ❑
Moving vehicles
❑ ❑
Electricity in use
6. Are hand and power tools to be used?
❑ ❑
Hand and Power tools
7. Will there be any overhead work? ❑ ❑
Overhead work
The following Risk Controls will be used for the identified hazards ( tick the risk controls you will be using)

All Contractors to be inducted to site (M);

Visitors to be escorted (M).

Site to be fenced off (M);

Hazard Boards and warning signage used (M);

All visitors to be inducted to site (M).

Toilets are available (M);

Running water is available on site (M);

Good hygiene practices to be maintained (M).

Keep clear off all designated roadways (M);

Hi-vis clothing to be worn (M);

Speed limit to be enforced on site (M);

Traffic management plan in place (M);

Designated areas for vehicle parking and deliveries (M).

RCDs to be used (M);

Leads and appliances to be in good condition and checked before use
(M);

RCDs, leads and appliances to be tagged and tested 3 monthly (M).

All workers using tools to be competent or supervised by a competent person (M);

Tools to be checked in good condition before use, with guards in place and leads tagged (M);

Equipment to be serviced regularly (M);

Workers to keep clear of any moving parts (M);

Appropriate PPE to be used (M);

Tools to be used correctly (M).

Tools are to be secured from falling (E);

Visitors to be kept clear of any overhead work (M);

The area under the work area to be isolated from workers (M).
Page 3 of 9

Answer the following questions relevant to the task you are doing ( Tick “Yes” or “No”)
Yes No
Hazard Identified
1. Are there any underground services in the vicinity of proposed excavation?
❑ ❑
Contact with live services
2. Could work being carried out effect adjacent buildings?
3. Could excavation adversly effect the public/ other employees?
4. Will work be done in the excavation?
❑ ❑
Property damage
❑ ❑
Injury to public/others
❑ ❑
Collapse
Entrapment
Personal injury
5. Will work be carried out on a road?
❑ ❑
Vehicles
6. Will there be any hazardous substances on site? e.g. paint, fuel, gas etc
❑ ❑
Hazardous substances
The following Risk Controls will be used for the identified hazards. ( tick the risk controls you will be using)

Dial before you dig (M);

Obtain diagrams and plans for underground utilities (M);

Locate and mark all underground utilities (M);

Isolate all utilities that may be effected by excavation (gas, elctricity, severage etc) (M);

Hand dig or pot hole carefully until services are uncovered and supported
(M).

Registered engineer to inspect site before work commences (E);

Excavation will not be deeper then the foundations of any adjacent building (M).

All non-essential people kept clear from work area (E);

Fencing to be erected around excavation (M);

Person designated to control access and entry to work area (M);

Warning signs in place and hazard board updated (M).

Over head protection provided (M);

Hard hats to be worn both inside and outside of the excavation (M);

Pump system in place to remove any excess water from excavation (M);

Ladder or stairway acces to be provided and fixed in place (M);

Suitable PPE provided (i.e gloves, safety glasses, protective clothing e.t.c)
(M).

Approval of local authority obtained (M);

Traffic management system in place (M).

Correct storage, handling and disposal techniques (M);

Licensed handlers used (M);

Required PPE to be used (M);

Hazardous Substance Register and Safety Data Sheets (SDS) to be available on site (M).
Page 4 of 9

Answer the following questions relevant to the task you are doing ( Tick “Yes” or “No”)
Yes No
Hazard Identified
7. Is Excavating machinery likely to create a noise hazard during operations?
❑ ❑
Noise
8. Will you be setting up Excavating equipment in an enclosed or semi enclosed area?
9. Will excvated material be stored near excavation?
10. Could works create dust ?
11. Could there be surface water present?
12. Could there be harmful gases present?
13. Will the job last more then a day?
❑ ❑
Carbon Monoxide
❑ ❑
Collapse
Entrapment
Personal injury
❑ ❑
Dust
❑ ❑
Surface water
❑ ❑
Harmful gasses
❑ ❑
Public/Personel injury
The following Risk Controls will be used for the identified hazards. ( tick the risk controls you will be using)

Noisy equipment to be substituted for less noisy equipment (E);

Non essential persons or visitors kept clear (E);

Hearing protection to be used at all times and noise levels monitored (M);

Equipment set up in enclosed spaces to be avoided (M).

Engine exhaust gases from diggers and vehicles are to be directed to the open air (M);

An extraction/ventilation system and/or air­supplied breathing apparatus to be used in confined areas (M).

All excavated or loose material to be stored at least 600mm from he edge of excavation (E);

Face is specially shored to allow for the increased load (M).

Frequent watering, oiling or chemical spraying of haul roads and working areas.
(M);

Dust masks or breathing apperatus provided to workers (M).

Surface water to be channeled away from excavation (M);

Local water sources isolated (M);

Sump pump available to remove intercpt ground water (M).

Test in advance of work commencing (E);

Isolate services (Gas, Sewerage, e.t.c.)(M);

Staff to be trained and competent surronding gasses and the risks and controls involved (M);

Forced ventilattion to be used (M);

Appropriate PPE to be used (M).

Excavation to be adequately fenced and warning signs erected (M);

Excavation to be inspected dily before work commences or after adverse weather conitions (rain, high winds e.t.c.) daily record of inspections to be kept (M).
Page 5 of 9

Answer the following questions relevant to the task you are doing ( Tick “Yes” or “No”)
14. Will you be using a Digger/Earth moving equipment?
15. Will there be any use of equipment near overhead power lines?
16. Will you require a delivery area?
17. Will you be using vehicles to remove excavated material?
Yes
❑
❑
❑
❑
No
❑
❑
❑
❑
Hazard Identified
Falling / Toppling Equipment
High Voltage
High Voltage
Moving vehicles and machinery
Digger moving parts
Moving vehicles
The following Risk Controls will be used for the identified hazards. ( tick the risk controls you will be using)

Equipment to be set up as recommended by the manufacturer or specified in operators manual (M);

Equipment set up is to be clear of overhead lines and fixed electrical equipment (DO NOT encroach within 4M) (M);

Digger is not to be used as a crane (M);

Daily pre-start check to be done and approved operaters only to operate any equipment (M).

Lines company to de-energise high voltage lines prior to comencing work
(E);

Lines company to Isolate high voltage lines us ing “tiger tails” or similar (M):

All equipment to be kept a minimum of 4M clear of high voltage lines unless authorised by lines company (M):

Spotter to be used while moving equipment (M);

Moved by competent operator only (M).

Access to areas around the delivery area to be restricted using barricades, safety mesh or danger tape (M);

Safety zone to be set up around delivery area (M);

Adequate lighting to be provided for work in low light or at night (M);

Appropriate warning signage to be put in place (M);

A clear area for delivery trucks is to be established (M).

All non-essential people to be kept from work site (M);

Designated work area set up prior to loading operations (M);

Traffic management plan to be implemented (M);

Safety observer to be used (M);

Non essential persons to be kept clear (M);

Only competent operators to use equipment (M).
Page 6 of 9

Answer the following questions relevant to the task you are doing ( Tick “Yes” or “No”)
Yes No
Hazard Identified
The following Risk Controls will be used for the identified hazards. ( tick the risk controls you will be using)
18. Will you be using an on site traffic controller ?
19. Will you be working at night or in poor lighting?
20. Could a confined space occur during excavation?
❑
❑
❑
❑
❑
❑
Moving vehicles and machinery
Poor Lighting/Visability
Confined spaces

Traffic controller and other workers to use high vis vests at all times (M);

All concrete trucks to have operational reversing beepers (M);

Traffic controller is to stay clear of hopper and reversing truck and remain visiable to the driver at all times (M);

Delivery drivers are to remain clear of discharge area until signalled to reverse into position by Traffic Controller (M).

Artificial lighting in trenches and open excavations to be used where there is insufficient natural light to be provided (M);

No lone work at night (M);

Clear communication procedures in place (M).

Permit to enter system to be implemented (M);

Test excavation for safe oxygen levels before and during work (M);

Breathing apparatus available on site (M);

Stand by person available at all times (M);

Trained and competent workers only in confined spaces(M);

Appropriate PPE to be worn at all times (M);

Use Confines Space Task Analysis and Entry Permit document (M).
if you answer yes to any of the following questions then your work must be notified in writing to Worksafe 24 hours prior to commencement of this work. If you are not sure refer to the
Approved Code of Practice (ACOP) for Excavations and Shafts for Foundations.
Answer the following questions relevant to the task you are doing o Will your excavtion be 1.5m or more deep? o Will your excavation have face is steeper than 1 horizontal to 2 vertical? (Is your excavation deeper than it is wide) o Could a confined space occur during excavation? o Will your excavation have a face greater than 5m?

Yes

No

Yes

No

Yes

No

Yes

No
Page 7 of 9

Any additional h azards you identify for the work to be undertaken that are not listed, should be written in the “Additional Site Information” box.
Please contact HazardCo on 0800 555 339 if you have an accident on the worksite.
Additional Site Information / Hazards
PPE Required Signage
Required
Safety Briefing Completed By: Date: Signed:
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Name:
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Workers Receiving Safety Briefing:
Name: