Site Specific Safety Plan

Use this form to submit your Site Specific Safety Plan. Please note that you must submit this form and receive approval from Transpower prior to any work activity commencing.

If you prefer to fill out a printed version of this form, download and print the pdf file contained on this page. You must then scan and email the completed form to the Transpower representative responsible for your contract. Work may not commence until we have reviewed and approved the Plan.

Downloads

121233.02 - Site Specific Safety Plan Form.pdf [ pdf 46.79 KB ]

To: *

Who is the Transpower representative responsible for your contract?

From: *

Who is the Contractor representative?

Work location: *

At which Site will the work take place?

For: *

What is the scope of the work to be completed?

We undertake as follows:

1. Workplace Control and Management:

On-site safety supervisor for this project is: *

What is the name of the on-site safety supervisor?

On-site safety supervisor phone number: *

2. Hazardous Works:

We have Hazardous Works associated with our contract: *

WorkSafe NZ has been advised of our Hazardous Works: *

WorkSafe notification is attached to this submission: *

Notification upload

Files must be less than 2 MB.
Allowed file types: pdf doc docx.

3. Risk and Hazard management:

Each day we will maintain an on-site pre-start form where site-specific hazards and appropriate controls to eliminate or minimise the risks will be recorded: *

We will prepare a written task analysis covering all hazards and appropriate controls associated with our works, and provide a copy before any work commences on site: *

Are there hazardous substances associated with our subcontract works: *

If yes, the appropriate Safety Data Sheets and emergency plans must be attached.

Safety Data Sheet 1

Files must be less than 2 MB.
Allowed file types: pdf doc docx.

Safety Data Sheet 2

Files must be less than 2 MB.
Allowed file types: pdf doc docx.

Safety Data Sheet 3

Files must be less than 2 MB.
Allowed file types: pdf doc docx.

Safety Data Sheet 4

Files must be less than 2 MB.
Allowed file types: pdf doc docx.

4. Communication / Employee participation:

The methods we use to communicate safety information to our employees are: *

Frequency of above communications: *

5. Emergencies:

Our First Aid kit is located at: *

Our First Aid person is: *

First Aid person's phone number: *

We have trained First Aid personnel and procedures in place on site to render assistance in the event of an accident / emergency: *

In the event of a site emergency or evacuation our personnel will report to our safety representative and assemble at the evacuation area shown on the Emergency Evacuation Plan: *

6. Accident reporting, investigation and records:

We have an accident / incident reporting / investigation system in place and keep a register: *

We will immediately notify all accidents, injuries and serious near misses to site management: *

We will immediately notify WorkSafe NZ if a Notifiable Event occurs while we are completing our work: *

7. Safety inspections and reviews:

We agree to undertake safety inspections and reviews: *

An example of our safety inspection documentation is attached: *

8. Training or induction:

All persons under our control on site are given a site specific safety induction: *

All persons under our control on site (including subcontractors) are appropriately qualified, competent, and / or fully supervised: *

9. Subcontractors:

Will you have subcontractors working for you on this scope of works: *

Who are they?

What will they be doing?

Leave this field blank