Pre-Task Analysis

Document Number: E6-07-004

Project Number: [________]

Company Name Start Time End Time

Date Area
In the case of an emergency the contact the following personnel:
Initials and Surname Contact Number
Client Representative
Drysys PE/ Manager
Drysys Safety Officer
Contractor Supervisor
Control Room
Ambulance
Hospital
Fire Department
Police

In the case of an Emergency all personnel must go to Assembly Point ________.

Explain what to do in the case of an Emergency (Where to go)

Emergency Personnel – When Required

Initials and Surname Contact Number
First Aider
Fire Fighter
Location on Site
First Aid Box
Fire Fighting Equipment
Chemical Shower
Eyewash Station
Other
(Checklist – Before Work Commences)
Physical Inspection Yes/N Corrective Measures
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Revision number: 2020-00
 Pre-Task Analysis
Document Number: E6-07-004
Project Number: [________]

A
Is the Area Safe to Enter
Are all Tools and Equipment Pre-Inspected
Is the Emergency Route Identified and
Communicated
Scaffold Checklist Done and Marked Safe Un-Safe
Correct P.P.E (Utilized & Available)
Lock –Out Required and in Place?
All Tools and Equipment Checked and Safe for
Use
Correct Permits for Application
Hot-Work☐ Working @ Heights☐ Confined Space ☐ Lock Out & Isolation ☐ Other:_____________________☐
The above list does not exclude and or waive any other checklist and or legal requirements!
(Checklist – After Work Close-Out)
Physical Inspection Yes/N Corrective Measures
A
Is the Area Safe and Clean?
Is Barricading Erected where needed?
All openings closed and covers put back in place?
Are all Tools and Equipment Removed from the
Area?
All Emergency Equipment Stored Correctly?
Scaffold Marked Un-Safe for use?
All Lock –Out Locks Removed?
Please return al Paperwork to the Drysys Office before Leaving the Site
Sign on/off at Before and After the Shift
I hereby certify that the area/s is safe and free of any possible hazards.

(Before Shift) Responsible Person: _________________________ ______________________

Print Name Signature

(After Shift) Responsible Person: _________________________ ______________________

Print Name Signature
Personal Protective Equipment (PPE) Recommended: (Check the box for recommended PPE):

Head Safety High Visibility

Safety Shoes Overall Lint Free Gloves Vest
Protection Glasses
☐ ☐ ☐ ☐ ☐ ☐ ☐

Other
Respirator Hearing Fall Arrest Welding Lock Out Lock
System Face Shield
Protection System Hood and Tag
☐ ☐ ☐ ☐ ☐ ☐ ☐
Other Safety Notes or Relevant Site Conditions:

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Revision number: 2020-00
 Pre-Task Analysis
Document Number: E6-07-004
Project Number: [________]

Responsible
# Task (What am I going to do?) Risk (What can go Wrong?) Control (How will I control the Risk?)
Contractor/Person

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Revision number: 2020-00
 Pre-Task Analysis
Document Number: E6-07-004
Project Number: [________]

Responsible
# Task (What am I going to do?) Risk (What can go Wrong?) Control (How will I control the Risk?)
Contractor/Person

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Revision number: 2020-00
 Pre-Task Analysis
Document Number: E6-07-004
Project Number: [________]

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Revision number: 2020-00
 [Document Title]
Document Number: 00-000
Project Number: [________]
Roll Call Check

Acknowledgement of Information
I hereby acknowledge that I have been informed and trained on this Pre-Task Analysis

Signature
Initials & Surname ID Number

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Revision number: 2020-00