TAKE FIVE Safety Form

NITRO EXPLOSIVES (T) LTD

STOP • THINK • IDENTIFY • CONTROL • CONFIRM

A. Employee & Site Details

Employee Name *

Employee ID *

Site *

Date

Time

B. Job / Task Description

Task Description * Tools / Equipment

C. TAKE FIVE Checklist

I have STOPPED and understood the job

I have THOUGHT about the risks involved

D. Hazard Identification

Explosives

Electrical

Mechanical

Working at Height

Vehicle / Traffic

Fire / Heat

E. Control Measures

PPE Required:

Helmet

Safety Boots

Gloves

Goggles

Permit to Work obtained

Toolbox talk conducted

F. Final Confirmation

I confirm that it is SAFE to proceed with this task

Employee Signature (Full Name)