WORK ORDER

Date:

__________________________________________________

Requested By: Location:

__________________________________________________ _________________________________________________

Contact Details: _______________________________________________________________________________________________

E 1 Hour

VU 2 Days

U 7 Days

R 14 Days

Description of Issue

Work Order Number:

Assigned To:

Date Task Commenced

Technician signature Date

TRACKING INFORMATION - OFFICIAL USE

Defect Found / Materials Used / Any Other Comments

Type of Work Order

Planned

Unplanned

Response Category

Tick the Category Box Below

Client signature Date

H1 H12

H2 H13

H3 H14

H4 H15

H5 H16

H6 H17

H7 H18

H8

H9 H19

H10 H20

H11 H21

Podium Steps Extension Ladder Mobile Tower Scaffold MEWP

Step Ladder Trestles & Staging Scaffold Other

Other:

C1 C10

C2 C11

C3 C12

C4 C13

C5 C14

C6 C15

C7 C16

C8 C17

C9

C20

C21

C23

C24

E. Other Control Measures / Safety Precautions Taken

F. Sign Off

PLEASE NOTE: All site operations must be in accordance with current Legislation, Ecolog Policies / Procedures and Training

Please Note: The Safest means of access must be chosen-apply the hierarchy of control

Ladders and Steps are to be used for low risk activities only and for a duration not exceeding 20min

Control Measures Control Measures

Hot Work' Permit required Mobile Tower scaffold, etc. training completed

Confined Spaces' Permit required Multiple personnel required for task

Permit to Dig / Excavate / Break Ground Required Relevant PPE eye/head/foot/ear/hand protection

Method statement BRIEFED Public/Third Parties protection established

COSHH assessment completed

DATE NAME SIGNATURE

Are existing site control measures / precautions in section D adequate to control the hazard in section B. If no, list the additional control measures

All members of staff involved in this task are to read the Risk Assessments and associated documentation. Once they have read or had read to

them the Risk Assessments and associated documents they are to sign the confirmation form below. It must be understood by all staff that this is

also a statement that they agree to implement / comply with said risk assessments.

Detail Below other identified hazards

A. Identified Work Risk Assessment

B. Hazard / Risk (Tick box(es) if hazard(s) identified)

Access at Height' training completed

Manual Handling' training completed

Job Safety Analysis in place for task

WORK ORDER / JSA

Does a Significant Health and Safety Risk exist during the task (Tick Appropriate Box) - Yes / No If Yes, complete sections B to E. If No, complete sections C & E and

carry on with the task. However, PLEASE NOTE: If you are unsure of the risk rating do not commence works, or Risk level alters during the task, complete all sections. For

further advice and guidance contact your Supervisor, Line Manager or HS&E Advisor / Manager

Hazard / Risk

There will be 'Working at Height' during the task

Hazard / Risk

There is a risk of fire

There is asbestos that is likely to be disturbed

Risk of falling Person/Objects (From or Through Roofs)

Risk of Falling Objects

Manual Handling risk identified

Risk of Slips, Trips or Fall on same level

The working environment poses a safety risk

Restricted space / confined space exists Excavation / Trenching

There is a risk to others/third parties

There will be hazardous 'Lone Working'

Personal injury from task or abuse

Electrical supplies appear unsafe or unable to isolate

Protective barriers required

Risk assessment made site specific Warning notices/signs correctly placed

Fall Protection measures (Priorities Collective) Toolbox Talk delivered

Use of Hazardous substances

Working with pressurized Systems

There is inadequate / poor lighting

Hearing protection is required

C. Means of Access to Work Area (If working at height select the safest method or state not applicable)

D. Control Measures / Safety Precautions & PPE (Tick box(es) if control measure(s) used)