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Take 5 / Start Work Risk Assessment

Five quick checks before starting any task: Stop, Look, Assess, Control, Proceed

Company logo

PAGE 1 OF 2

Worker & Task Details

Worker name

Date

Time

Location / site

Task / job

Permit required?

1 STOP Am I fit for work?

I am physically fit and not fatigued I am mentally alert and focused I am not under the influence of drugs or alcohol I have the right training and competency for this task I have read and understood the SWMS / JSA for this task

2 LOOK What are the hazards? (tick all that apply)

Fall from height Crush / pinch point Electrical Heat / cold stress Chemical / hazardous substance Noise Confined space Moving plant / vehicle Manual handling Slip / trip Working alone Other: _______________

3 ASSESS What could go wrong? Who could be harmed?

Take 5 Risk Assessment - Page 2 of 2

Date

Worker

4 CONTROL What controls are in place or needed?

Work down the hierarchy of controls. List each control in place for the hazards identified.

Control level	Controls in place for this task
Elimination
Substitution
Engineering controls
Administrative controls
PPE

5 PROCEED: Is it safe to proceed?

YES: All hazards controlled. Safe to start work.

NO: Do NOT start. Report to supervisor immediately.

If NO: Reason for Not Proceeding / Reported To

Declaration

I declare that I have completed this Take 5 risk assessment before starting the task described above. I have identified the hazards, assessed the risks and confirmed that adequate controls are in place. If it was not safe to proceed, I have reported to my supervisor and will not commence work until the hazards are controlled.

Worker Sign-off

Signature

Print name

Date & time

Supervisor Sign-off

Signature

Print name

Date