Checklists and Forms

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

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.

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

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

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

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

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.

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.

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.

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. 

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

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

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

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.

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.

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.

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.

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

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

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.

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

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. 

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. 

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.

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.

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.

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

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

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.

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.

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

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

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.

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.

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

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

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

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.

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.

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.

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.

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

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.

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.

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.

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.

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.

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

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

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 (WHS-CLF-71)

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)

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

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

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.

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.

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.

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.

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.

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

This is an example of a Fitness for Work Assessment tool. Fitness for work is a very emotive matter and can be challenging to manage. Ensure there is adequate human resources support when seeking to implement and manage this type of policy and procedure. Assessments are role specific and should be developed with the help of suitably qualified and experienced allied health professional and / or physician (health care professional).

This guide has been developed to help employees with the completion of equipment inspections prior to use, to assist in the identification of any potential hazards or risks.

This guide has been developed to help employees with the completion of equipment inspections prior to use, to assist in the identification of any potential hazards or risks.

This guide has been developed to help employees with the completion of equipment inspections prior to use, to assist in the identification of any potential hazards or risks.

This guide has been developed to help employees with the completion of equipment inspections prior to use, to assist in the identification of any potential hazards or risks.

This form is to help in determining the required controls to manage new and trial substances in the workplace and to establish if the hazards and risks associated with the substance will be an acceptable risk to the organisation.

Prior to the purchase of goods or services, hazards should be identified using a pre-purchase checklist. All items identified as relevant on the checklist should ideally be actioned prior to purchase or introduction into the workplace.

This registration form is to enable suppliers to respond to required criteria for a fair and equitable review and evaluation for becoming a preferred supplier.

This form can be used to record training such as toolbox talks to team members to register their attendance.

This checklist is used for internal audits of the Work Health & Safety Management System (WHSMS). The aim of the audit is to determine whether the WHSMS:

1.     conforms to planned arrangements and requirements of the WHSMS;

2.     has been adequately implemented and maintained; and

3.     is effective in meeting the businesses WHS management commitments, objectives and targets.

This schedule can be used to plan Work Health & Safety Management System (WHSMS) audits. 

This workbook provides employees with the content of the training presentation (WHS-EDU-04) as well as an area to document notes during the training session. The workbook should be printed and provided to the employees at the beginning of the training presentation session.

This assessment should be used to check an employee's understanding of the training content (WHS-EDU-04) after the presentation.

This is the answer sheet for questions in WHS-EDU-04.2 - Injury Management & Recovery at Work Training for Team Members Assessment, which can be used by managers or trainers.

This form is used to advise the workforce of who the First Aid Personnel are for each departments or the site. 

This form is used to advise the workforce of who the Fire Wardens are for each departments and/or site. 

This document can be used to schedule an organisations WHS Training.

A suitable duties list provides the treating doctor with a list of tasks 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.

Making contact with the treating doctor as soon as possible following an injury is important. This letter can be used to provide information to the treating doctor regarding the injury management support and suitable duties available in your workplace.

Prior to conducting hot works, hazards should be identified using the hot works permit. All item identified as relevant on the checklist should ideally be actioned prior to the commencement of activity in the workplace.

Prior to the use, storage and handling of hazardous chemicals in the workplace, the hazardous chemical risk assessment form should be completed to identify hazards. All items identified as relevant to the risk assessment should ideally be actioned prior to using, handling and/or storing hazardous chemicals.

This working from home self-assessment checklist is to assist in ensuring your work environment is safe and your workstation is ergonomically set-up. 

This checklist template can be used to create a workplace inspection checklist specific to a work location, department, area or operation to assist with the identification of hazards, risks, safety issues and equipment non-compliance within the workplace.

This guide has been developed to help employees with the completion of equipment inspections prior to use, to assist in the identification of any potential hazards or risks.

The purpose of this procedure is to eliminate the risk of fire and/or explosion occurring as a result of hot works.

Prior to starting any high-risk work, the person in control of the team shall review the relevant works to identify hazards that may result in an injury to a person and to identify control measures to minimise the risk and if required

All safety critical task/activities require a Permit to Work

The purpose of this form is to provide with an effective internal control framework for supporting preferred service providers (contractors) in meeting, as far as reasonably practicable, their work health and safety obligations and protecting all persons from the hazards and risks associated with their work activities and the business undertakings

Refer to Critical Operations Procedures Manual to complete this form.

Refer to Critical Operations Procedures Manual to complete this form. This permit is to be used in accordance with Contractor Site Entry Permit.

This checklist is designed to assist persons conducting a business or undertaking (PCBU) in identifying safety concerns, relating to manual handling and hazardous manual tasks, in the workplace. The checklist may serve as a tool to eliminate or otherwise reduce the risk of injuries sustained due to manual handling exposure. 

This checklist can be used to help identify a genuine concern for an unacceptable risk of injury / illness to a worker and should be used in a manner consistent with the relevant supporting policy, procedure, and risk management guide.

This checklist can be used to help identify a genuine concern for an unacceptable risk of injury / illness to a worker and should be used in a manner consistent with the relevant supporting policy, procedure, and risk management guide.