Checklists and Forms

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WHS HSR / Committee / Working Group Member Nomination

Form for the nomination of a working group Health and Safety Representative (HSR) and or a WHS Committee / Working Group Member.

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WHS Provisional Improvement Notice (PIN)

A Provisional Improvement Notice (PIN) is a notice that is issued to a person requiring them to address a health and safety concern in the workplace. A PIN may be issued if a HSR reasonably believes that a person is contravening or has contravened a provision of the Act in circumstances that make it likely that the contravention will continue or be repeated. A HSR can issue a PIN only if the HSR has completed an approved HSR training course, or previously completed that training when acting as a HSR of another work group.

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WHS Training Attendance Form

This form is used to record the details of all participants that attend face to face WHS training sessions.

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Toolbox Talk Attendance Form

This form is used to record the details of all participants that attend face to face toolbox meetings.

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WHS Election Form

Form for the election of nominated working group Health and Safety Representatives (HSR) and or a WHS Committee / Working Group Members.

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WHS Committee or Working Group Meeting Agenda

This form can be used to set the agenda for a WHS Committee / Working Group meeting.

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WHS Committee or Working Group Meeting Minutes

This form can be used to minute the outcome of a WHS Committee / Working Group meeting as well as record and track any action items agreed.

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WHS Consultation Form

This form can be used to record feedback received through consultation either directly with the workforce or through Health and Safety Representatives (HSRs) or A WHS Committee / Working Group.

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Workgroup and Health and Safety Representative (HSR) List

This form can be used to display the details of Health and Safety Representatives (HSRs) and / or WHS Committee / Working Group Members to inform the workforce of WHS consultation arrangements.

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Emergency Evacuation Drill Checklist

This checklist is used to record the details and verify the effectiveness of an emergency evacuation and response to an emergency situation when it occurs at a workplace. 

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Bomb Threat Checklist

This checklist is used by employees to record the details of a bomb threat that has been received via phone within the workplace. 

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First Aid Kit - Content Checklist

This checklist is used as a guide to assist in the maintenance of required contents within section first aid kits.

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Visitor Induction Checklist

This checklist is used to inform site visitors of the site rules, facilities available and their Work Health and Safety responsibilities whilst attending site.

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Emergency Evacuation Debrief Form

This form is used to document occasions when emergency evacuation procedures are activated, to assess whether the evacuation was conducted satisfactorily whilst assisting with the identification of any short comings or opportunities.

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Emergency Response Flip Chart

This flip chart is used to assist employees to determine what actions are required of them in the event of an emergency situation such as fire, bomb threat or other emergency situations.

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Personal Emergency Evacuation Plan

This form is used to record the specific planned evacuation details for an individual who may not be able to reach a place of safety unaided or within a satisfactory period of time in the event of an emergency.

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Forklift Competency Assessment

This checklist forms part of your formative assessment and is used to confirm that a forklift operator has the practical knowledge to operate a forklift within the workplace.

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Emergency Personnel Poster

This form is used to advise the workforce of who the Emergency Response Team and Safety Representatives are for the site. 

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Risk Assessment Form

This form can be used to document a risk assessment and a risk control implementation action plan.

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Injury Response Process Flowchart

This flowchart provides information to your employees on what to do in the event of a workplace injury. It can be adapted to your workplace and displayed on a safety noticeboard and next to your first aid kits.

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Injury Management Process Flowchart

This injury management process flowchart is for managers and supervisors to help them understand the key actions required in the management of an injury.

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Injury Pack for Leaders

The purpose of this pack is to provide managers and supervisors with information regarding your organisation's early intervention and injury management processes. It aims to support you to assist your employees in the event of a workplace injury or illness. 

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Injury Pack for Team Members

The purpose of this pack is to provide an injured employee with information regarding your early intervention and injury management process. It aims to support your injured employees to access timely and suitable medical treatment, provide assistance to stay at or return to work and offer proactive support while you are recovering. 

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Obtaining & Releasing Personal Information Consent Form

This form can be used to obtain consent from your injured employee for sharing personal information relating to a work related injury.

This list should be used with the Letter to treating practitioner WHS-CLF-18.2.

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Letter to treating practitioner

Making contact with the treating doctor is important. This letter can be used to provide information to the treating doctor regarding the injury management support available in your workplace.

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Suitable Duties List (Mechanical Workshop)

The suitable duties list provides the treating doctor with a list of duties to allow the injured employee to recover while at work. You adapt this list to your workplace or create your own using this as an example.

This list should be used with the Letter to treating practitioner WHS-CLF-18.2.

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Personal Injury / Illness Consent Form

This form can be used to obtain consent for sharing personal information relating to a non-work related injury or illness.

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Personal Injury / Illness Capacity to Work Form

This form can be used to obtain fitness for work information relating to a non-work related injury or illness.

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Return to Work Coordinator Checklist

An organisation’s Return to Work (RTW) Coordinator plays a key role in supporting employees with a work-related injury or illness to remain at or return to work. Together with the injured employee, manager/supervisor and insurance case manager, RTW Coordinators are responsible for developing and implementing recovery at work solutions.

This checklist is aimed to assist RTW Coordinators consider, develop and implement injury management and RTW systems and processes for their organisation.


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Injury Management Case Note Template

Keeping detailed case notes of conversations, meetings and consultations in relation to an injury or illness is very important. This form will help Return to Work Coordinators keep notes on recovery at work and claims management actions carried out.

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Recover at Work Plan Template

This template is aimed to assist Return to Work Coordinators document the suitable work duties offered to an injured employee.

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Safety Event Report Form

This form is used to record all safety events including hazards, injuries, incidents and near misses.

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Safety Event Report and Investigation Form

This form is for the reporting and investigation of safety events including injuries, incidents and near misses.

The form combines the safety event reporting and safety event investigation forms.

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Safety Event Investigation Form

This form is used to investigate safety events, including injuries, incidents and near misses. The aim of an investigation is to identify the factors that contributed to the event so that corrective actions can be made to minimise the risk of a similar event occurring.

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Safety Event Witness Statement

This form is used to collect a statement from a witness to a safety event, including injuries, incidents and near misses.

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New Employee Checklist

This checklist is used to ensure that new employees receive the required information when being inducted.

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Workstation Ergonomics Checklist

This is a self-assessment checklist to assist with the ergonomic set-up of a workstation.

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Tyre Fitting Machine Inspection Checklist

This checklist is for the pre-operation inspection of a Tyre Fitting Machine and is used to identify any faults or concerns with the machine.

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Wheel Balancing Machine Inspection Checklist

This checklist is for the pre-operation inspection of a Wheel Balancing Machine and is used to identify any faults or concerns with the machine.

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Drug and Alcohol Screening Reasonable Cause Checklist

This checklist is used by managers and supervisors to assist them to determine if there is reasonable cause to conduct drug and alcohol testing on an employee or service provider / supplier employee.

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Positive / Non Negative Drug and Alcohol Checklist

This checklist is used by managers and supervisors to assist them to ensure that the correct processes have been followed, when a positive / non negative drug and/or alcohol test result has been identified for an employee or service provider / supplier employee.

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Vehicle Hoist Inspection Checklist

This checklist is for the pre-operation inspection of a Vehicle Hoist and is used to identify any faults or concerns with the hoist.

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Drug and Alcohol Test Acknowledgement and Consent Form

This form is used by an employee or service provider / supplier employee to refuse or consent to undertake an organisations drug and alcohol testing process.

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Doctors Letter for Prescription Medication

This letter is used by an employee to verify the taking of any ongoing prescription or non-prescription medications that may influence the outcome of a drug test.

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Mobile Lifting Equipment Inspection Checklist

This checklist is for the pre-operation inspection of mobile lifting equipment such as trolley jacks, jack stands, transmission jacks and engine cranes and is used to identify any faults or concerns with the equipment.

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Service Provider Document Request Form

This form is used to request required Work Health and Safety documentation from a service provider / contractor prior to their appointment to conduct works on site.

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Forklift Pre-Start Inspection Checklist

This checklist is used by an employee to complete a pre-start inspection on a forklift to ensure that it is fully operational prior to use.

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Change Request Form

This form supports the Change Management Procedure, providing a mechanism to ensure changes are implemented in a planned and systematic manner.

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Asset Transfer Form

This form is used to record the transfer of assets such as plant, equipment and machinery between sites.

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Change Management Checklist

This form supports the Change Management Procedure, providing a mechanism to ensure changes are implemented in a planned and systematic manner, linked to the Change Request Form (WJS-CLF-71)

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Change Request Asset Review Form

This form supports the Change Management Procedure, providing a mechanism to ensure changes are implemented in a planned and systematic manner, linked to the Change Request Form (WJS-CLF-71)

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Workplace Inspection Schedule

This form is used to assist in the scheduling of workplace inspections.

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Personal Injury / Illness Return to Work Plan Template

This template is aimed to assist businesses document the suitable work duties offered to an employee with a non work related injury or illness.

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Parts I Warehouse Inspection Checklist

This checklist is used by persons who are completing a Workplace Inspection within the Parts I Warehouse to assist with the identification of hazards, risks, safety issues and equipment non-compliance within the workplace.

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Workshop Inspection Checklist

This checklist is used by persons who are completing a Workplace Inspection within the Workshop to assist with the identification of hazards, risks, safety issues and equipment non-compliance within the workplace.

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Office Inspection Checklist

This checklist is used by persons who are completing a Workplace Inspection within the Office to assist with the identification of hazards, risks, safety issues and equipment non-compliance within the workplace.

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Showroom I Car Yard Inspection Checklist

This checklist is used by persons who are completing a Workplace Inspection within the Parts I Warehouse to assist with the identification of hazards, risks, safety issue and equipment non-compliance within the workplace.

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Fuel Station Inspection Checklist

This checklist is used by persons who are completing a Workplace Inspection within the Fuel Station to assist with the identification of hazards, risks, safety issue and equipment non-compliance within the workplace.

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Noise Hazard Identification Checklist

This form is used by managers and supervisors to assist them in identifying areas that may need to have an Environmental Noise Assessment conducted.

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