Health and Safety Audit Form

(Version 0.21) Black Auckland Council Logo

Site Details
Date:
Site Address:
Work Order Number:		Weather:
Region:
Main Contractor:		Subcontractor:
Audit Representatives
Contractor Rep:		Council Rep:
Type of Works Being Completed
Work Type:		Work Type Other:
Area Of Work:
Health and Safety
Induction Completed?	Yes No	Standard of Induction Given:	1 2 3 4 5
Hazard ID Completed?	Yes No	Standard of Hazard ID Completed:	1 2 3 4 5
Site Emergency Plan:	Yes No	Standard of Site Safety Plan:	1 2 3 4 5
Have Residents Been Notified?	Yes No N/A
Services Located/Plans Onsite:	Yes No N/A	Standard of Site Services Markout:	1 2 3 4 5
3rd Party Permits Onsite (If Required):	Yes No N/A
3rd Party Permits Used:	Watercare Chorus Electrix Vector Kiwirail Other	3rd Party Permits Used Other:
PPE Being Used:	Hardhat Hi-Viz Safety Boots Glasses Gloves Hearing Pro. Masks	PPE Used Other:
		All PPE Identified:	1 2 3 4 5
		PPE Identified being used?:	1 2 3 4 5
Spill Kits Available Onsite?	Yes No N/A	Spill Kit Fully Stocked:	1 2 3 4 5
Fire Extinguisher Available Onsite?	Yes No N/A
Extinguisher Currently Certified?	Yes No N/A
Electrical tools/ power supplies onsite?	Yes No N/A	Do all the powertools and power supplies have current test and tag?	1 2 3 4 5
All electrical tools are connected to an RCD?	Yes No N/A	Standard of electrical safety onsite?	1 2 3 4 5
		Site Clean and Tidy?	1 2 3 4 5
General Comments:	Corrective Actions

COVID Safety Requirements
Current Covid Alert Level	1 1.5 2 2.5 3 4
Covid PPE Available	Mask Gloves Hand Sanitiser
Traffic Management
Traffic Management Plan:		TMP Plan Number:
STMS Available:		TMP Setout As Per Plan:	1 2 3 4 5
General Comments:	Corrective Actions

Confined Spaces/Working At Height Planning a Confined Space Entry
Permits Being Used?	Yes No N/A	Permit Information Correct?	1 2 3 4 5
Gas Detector Certification Current?	Yes No N/A
Tripod Certification Current?	Yes No N/A	Safety Equipment Certifications?	1 2 3 4 5
Harness Certification Current?	Yes No N/A	Safety Equipment Condition?	1 2 3 4 5
Work exceeding 5m in depth?	Yes No N/A
If Yes, is Work Safe Notification onsite?	Yes No N/A
Worksafe Hazardous Works Notification Form
Fall/CSE Area Protected? (barrier,tape,fence)	Yes No N/A	Standard of Area Protection?	1 2 3 4 5
General Comments:	Corrective Actions

Open Excavations/Trenching Worksafe Guidance for Trenching
Work Area Protected? (barrier,tape,fence)	Yes No N/A	Standard of Area Protection?	1 2 3 4 5
Excavation Exceeds 1.5m in Depth?	Yes No N/A
Does Depth Exceed Width?	Yes No N/A
If Yes for Depth and Excavation is Work Safe Notification onsite?	Yes No N/A
Worksafe Hazardous Works Notification Form
For Works Exceeding 1.5m in Depth is Shielding or Battering in Place?	Yes No N/A	Is Shielding or Battering Adequate?	1 2 3 4 5
Does shielding extend past the top of the excavation?	Yes No N/A
For excavations over 1.5m in depth is a gas detector being used?	Yes No N/A
Are Works Within Tree Driplines?	Yes No N/A
If works are within the dripline has an arborist been consulted?	Yes No N/A	Standard of Protection for Trees etc?	1 2 3 4 5
Is Silt Control Required?	Yes No N/A	Is Silt Control Adequate?	1 2 3 4 5
General Comments:	Corrective Actions

Audit Result
Fail Low Pass Pass High Pass Excep
Contractor Signature:	Engineer Signature:

Date:	Date:

Health and Safety Audit Form

Site Details

Audit Representatives

Type of Works Being Completed

Health and Safety

COVID Safety Requirements

Traffic Management

Confined Spaces/Working At Height

Open Excavations/Trenching

Audit Result