Toggle navigation
Contractor Logo
*
Contractor Logo
Contractor Contact Person
Contractor Contact Person
Contractor Contact Person Email Address
Contractor Contact Person Email Address
Project Name
Project Name
Project Short Name
Project Short Name
Project Address
Project Address
Contract Start Date
Contract End Date
Contract Period (in months)
Estimated Maximum Number of Persons on Site
Estimated Maximum Number of Persons on Site
Client/ Principal Contractor Name
Client/ Principal Contractor Name
Client’s /PC OHS Contact Name
Client’s /PC OHS Contact Name
Client Contact Person’s / Agent
Telephone no. or email
Scope of Works: Activity 1
*
Scope of Works: Activity 2
Scope of Works: Activity 3
Scope of Works: Activity 3
CEO Designation [OHSAct Section 16(1)]
Initials & Surname
Contracts Manager [OHSAct Section 16(2)]
Initials & Surname
Construction Work Supervisor
Name & Surname
Construction Work Supervisor Mobile Number
Assistant Construction Work Supervisor
Construction Vehicles and Mobile Plant Inspector
Electrical Installations & Machinery Supervisor
Emergency Co-ordinator
Environmental Officer [OHSAct Section 8]
Fire Equipment Inspector
Hand Tool Inspector
Hazardous Chemical Substances Supervisor [HCSR 3 (3)]
Health & Safety Committee Member [OHSAct 19(3)]
Health & Safety Representative [OHSAct 17(1)]
Health and Safety Officer
Incident & Accident Investigator [GAR 9(2)]
Ladder Inspector [GSR 13A]
Lifting Equipment Inspector [DMR 18(5)&(10)(e)]
Material Hoist Inspector
Portable Electrical Power Tool Inspector [EMR 9]
Risk Assessor
Scaffold Erector
Scaffold Inspector
Scaffold Supervisor
Scaffold Team Leader
Stacking and Storage Supervisor
PWelding, Flame Cutting & Soldering Operator [GSR 9(1)(a)]
Mobile Crane Operator
Banksman
Lifting tackle Inspector
Demolition Supervisor
Please provide signature
Clear
Undo
Submit