Form Name: Task Analysis Sheet Form Ref.

HSR 09
Project Name: Project No.

Task Sheet Ref. No: TS No.

Job Task Activity: Date:
Location: TS Produced By:
Supervisor Of Work: Programme:
Intended Start Date: Intended Finish Date:
Permits Required (Tick)
☐ Excavations over 1.5m ☐ Confined Spaces ☐ Scaffold over 5m ☐ Elect/Gas/Fibre Optics
☐ Permit to dig ☐ TMP ☐ Structures over 5m ☐ Close approach
☐ Hot works ☐ Service plans ☐ Heavy lifts over 500ks ☐ Other:
Identify Potential Hazards (Tick) and summarise overleaf
☐ Chemical Burn ☐ Un-even/sloping/soft ground
☐ Trench collapse ☐ Electrical Shock
☐ Particle in Eye ☐ Atmosphere
☐ Loud Noise ☐ Traffic
☐ Slips / Trips / Falls ☐ Vibrating plant
☐ Elevated Loads ☐ U/ground Services
☐ Manual Handling ☐ Burns
☐ Mobile machinery ☐ Overhead services
☐ Pinch points ☐ Other
Traffic: Requirements / Equipment (Tick)
☐ Low Volumes ☐ Level 3 Road ☐ Detour closure ☐ Road closed closure
☐ Contra Flow
☐ Level 1 Road ☐ STMS + TC ☐ Mobile closure ☐ Stop/Go closure
☐ Temp Traffic Lights
☐ Level 2 Road ☐ 2 Way Radio ☐ Lane closure ☐ Shoulder closure
Identify Potential Environment Risks (Tick) and summarise overleaf
Are there any environmental risks associated with the task? Yes ☐ No ☐ If ‘Yes’, what controls do you need?
☐ Cesspit Protection ☐ Sediment Control ☐ Cement Wash Collection ☐ Other (State)
☐ Dust Control ☐ Spill Prevention ☐ Noise Minimisation
Required Resources: ☐ Spill Kit ☐ Sand bags, Filter Sock, etc ☐ Geo-textile cloth
Steps Description
1. Sequence of Work: Brief bullet-point description of methodology
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2. Plant & Equipment: List items required

  
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3. Materials: List items required (Tick associated ☐ if MSDS Sheet is available)

       ☐        ☐        ☐
       ☐        ☐        ☐
4. Additional PPE: Requirements for specific tasks
☐ Eye Protection ☐ Safety Harness ☐ Buoyancy device
☐ Weather protection
☐ Dust Mask ☐ Flood Lights ☐ Fire extinguisher
☐ Other:
☐ Gloves ☐ Atmosphere Detector ☐ First Aid Kit
☐ None
☐ Hearing protection ☐ Life line ☐ RCD (Circuit breaker)

Form No. SQE-010-F-006 / Rev 4.0

Date: 2020/01/10 Page 1 of 5
 Health & Safety Risk Assessment ONLY
Consequence Likelihood Risk Rating (multiply Consequence by Likelihood)
1 – Insignificant: no injuries requiring
1 – Rare: may occur in exceptional circumstances 1–3 = Low / broadly acceptable with appropriate controls
treatment
2 – Minor: first aid treatment 2 – Unlikely: could occur at some time 4–6 = Moderate / acceptable with appropriate controls

3 – Moderate: MTI – return to work 3 – Possible: should occur at some time 8 – 12 = High / Tolerable [higher level management approval)

4 – Major: LTI – serious harm 4 – Likely: will probably occur in most circumstances 15 – 25 = Very High / intolerable/ Significant Risk

5 – Catastrophic: fatalities 5 - Almost Certain: is expected to occur in most circumstances

LEVEL OF RISK (RISK RATING)

CONSEQUENCE
LIKELIHOOD 1 - Insignificant 2 - Minor 3 - Moderate 4 - Major 5 - Catastrophic

5 - Almost certain M-5 H-10 VH-15 VH-20 VH-25

4 - Likely M-4 H-8 H-12 VH-16 VH-20

3 - Possible L-3 M-6 H-9 H-12 VH-15

2 - Unlikely L-2 M-4 M-6 H-8 H-10

1 - Rare L-1 L-2 L-3 M-4 M-5

Form No. SQE-010-F-006 / Rev 4.0

Date: 2020/01/10 Page 2 of 5
In completion of this section, please refer to the Project Risk Register (HSR01/02). Link
Insert the information relating to this activity, as shown in the completed HSR02, within the table below.

Hazard Risk Primary Hierarchy Controls to Eliminate / Minimise (E/M) Residual Risk Person(s)
Risk Control Rating Responsible
Rating Applied

Form No. SQE-010-F-006 / Rev 4.0

Date: 2020/01/10 Page 3 of 5
 Hazard

Form No. SQE-010-F-006 / Rev 4.0

Date: 2020/01/10 Page 4 of 5
The following register is used to confirm that all persons involved in carrying out this work are aware of and understand the
contents of this document.

Name Company Signature Time

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Form No. SQE-010-F-006 / Rev 4.0

Date: 2020/01/10 Page 5 of 5