Site Clearance Certificate
Tasks
Tasks Involved
High Risk
Medium Risk
Low Risk
General Information
Site Name
Date
DD slash MM slash YYYY
Contact Number
Survey Number
Person in Charge (RMM)
First
Last
Method Statement Correct?
Yes
No
Number of Workers
Description of Work
Engineer Authorisation
Signed
(Only required for high risk tasks)
Date
DD slash MM slash YYYY
Are Isolation Procedures Required?
Yes
No
(If YES, site must be aware of the procedure)
Hazards
Additional Hazard 1
Risk
High
Medium
Low
How to Reduce / Eliminate Risk
Remaining Risk
High
Medium
Low
Add Another Additional Hazard?
Yes
No - Continue to Next Section
Additional Hazard 2
Risk
High
Medium
Low
How to Reduce / Eliminate Risk
Remaining Risk
High
Medium
Low
Add a Third Additional Hazard?
Yes
No - Continue to Next Section
Additional Hazard 3
Risk
High
Medium
Low
How to Reduce / Eliminate Risk
Remaining Risk
High
Medium
Low
Add a Fourth Additional Hazard?
Yes
No - Continue to Next Section
Additional Hazard 4
Risk
High
Medium
Low
How to Reduce / Eliminate Risk
Remaining Risk
High
Medium
Low
Add a Fifth Additional Hazard?
Yes
No - Continue to Next Section
Additional Hazard 5
Risk
High
Medium
Low
How to Reduce / Eliminate Risk
Remaining Risk
High
Medium
Low
Add a Sixth Additional Hazard?
Yes
No - Continue to Next Section
Additional Hazard 6
Risk
High
Medium
Low
How to Reduce / Eliminate Risk
Remaining Risk
High
Medium
Low
Add a Seventh Additional Hazard?
Yes
No - Continue to Next Section
Additional Hazard 7
Risk
High
Medium
Low
How to Reduce / Eliminate Risk
Remaining Risk
High
Medium
Low
IMPORTANT: A New Certificate Is Required On Each Day Of The Job - Update If Additional Hazards Emerge Or Circumstances Change
Further Work / Materials Required to Complete
Before Work Commences
As the Contractor, I confirm that I will carry out the work as agreed.
First
Last
Date
DD slash MM slash YYYY
On behalf of the site, I have reviewed and agree to these work arrangements.
First
Last
Date
DD slash MM slash YYYY
Check List
Check List
Certificate fully completed
Safety Method Statement available*
Have you shown the site your Safety Method Statement?
Certificate signed by contractor/retailer
All obvious hazards identified and precautions taken
Did a near miss occur whilst on site?
Work Completed Safely
Retailer Signed
First
Last
Date
DD slash MM slash YYYY
Retailer Email Address
This must be provided to enable delivery of the Retailer's copy of the completed form.
Comments
Declaration
I confirm all the information on this form is correct
I confirm all the information on this form is correct and that by pressing Submit, a copy of this form and associated declaration will be sent to both parties and recorded digitally by RM Maintenance Ltd in accordance with our Privacy Policy, a copy of which can be found on our website.
Phone
This field is for validation purposes and should be left unchanged.
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