Builder Name*
Work Detail
Address*
Order #*
Installation Date*
General State of the Work Site is SAFE and tidyYesNo
Ceiling has no cracksYesNo
Floors clean and tidyYesNo
Lights in place & in working orderYesNo
A safe working environment existsYesNo
Is the Ceiling lining made of asbestos?YesNo
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General State of Work Site is SAFE and tidyYesNo
Ceiling has no cracks YesNo
Insulation packaging removed from siteYesNo
Access Aperture cleanYesNo
Default Minimum clearance of insulation around all recessed lights And electrical equipment achieved as per AS/NZS 3000:2007YesNo
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Upload at least 6 pictures including the site board
Probability—Please choose an option—Not ApplicableA - Common or RepeatingB - Known to occurC - Could occurD - Not likely to happenE - Practically Impossible
Consequence—Please choose an option—Not Applicable1 - Fatal or permanent serious injury2 - Lost time injury or illness3 - Medical treatment required4 - First aid treatment5 - Incident report only
Risk—Please choose an option—Not ApplicableHighSignificantModerateLow
Control Measure
Eliminate, Isolate, minimise to a safe level (state how)
Person
The person responsible to make this happen
Other Hazards
Probability—Please choose an option—A - Common or RepeatingB - Known to occurC - Could occurD - Not likely to happenE - Practically Impossible
Consequence—Please choose an option—1 - Fatal or permanent serious injury2 - Lost time injury or illness3 - Medical treatment required4 - First aid treatment5 - Incident report only
Risk—Please choose an option—HighSignificantModerateLow
Work site evaluated by
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Date
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Builder's Confirmation
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Assessor's Name*