Health and Safety form - PNZ Conference 2019

Business Information

Trading Name:

Trade:

Postal Address:

City

State/Province

Zip/Postal

Contact Person Name: *

Phone *

Email *

Health and Safety Management

Person in charge of Health and Safety onsite: *

Phone *

Email *

Date of your last Health and Safety Review: *

How often do you hold toolbox meetings? *

Not applicable

FrequencyFrequency

Accident/Incident/Near Miss

Have you had a “Notifiable” incident within the past 12 months that was notified to WorkSafe while on site at a conference?

Yes

If yes, please provide details.

Please provide a copy of an Incident/Near Miss Form that you use while on site at the Conference

Maximum upload size: 10.49MB

Hazard Management – only complete if you are bringing hazardous substances onsite

Will you be bringing any hazardous substances or materials on site?

Yes

Section: Hazardous substances

Please list all hazardous substances or materials.

Where are your Safety Data Sheets located?

Please provide a copy of your Hazard Register relevant to the work you will perform onsite (if relevant)

Maximum upload size: 10.49MB

Do you identify all hazards and controls that are required before commencing work?

Yes

Where do you record these

Are your staff required to wear PPE?

Yes

What PPE are your staff and contractors required to wear?

Emergency Procedures

Will your staff have a First Aid Kit onsite? *

Yes

What will your staff do in the event of an incident?

Sub-Contractors – only complete if you are having a sub-contractor complete your build

Do you engage sub-contractors? *

Yes

Section: Sub-Contractors

How do you assess the competency of your sub-contractors Please provide details...

How do you induct your sub-contractors Please provide details...

Training – as relevant to being onsite at the conference

Are your Workers qualified or been trained for the work they will undertake *

Yes

Section: Training

Please describe what training they have received.

Please provide a sample copy of an Employee Training Record

Maximum upload size: 10.49MB

Office Use Only

Approved by:

Expiry Date:

Declaration

In submitting this application, we confirm that:

We are aware of our obligations and responsibilities and will comply with the Health and Safety at Work Act 2015 and its subsequent additions and amendments, all industry codes of practice and regulations, and will hold the relevant certification and permits for the work to be carried out.
We will provide our workers with the appropriate personal protection equipment and ensure that they will be fully trained and competent to use the machinery, equipment, tools and substances necessary to carry out the work that this application covers.
Our workers shall agree to attend all site inductions and be bound by any site-specific rules including:

reporting any incident or near miss, and
reporting any potential hazard that has been identified during the course of our
business, and
attending any drug and alcohol screening test in accordance with the clients’ health and safety policy

We will ensure that any Subcontractors we may use will adhere to these requirements.
We will seek approval from the client or site management for disposing of any waste onsite
arising from the contract.

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