Template

Take 5 Safety Form

by Folkert Drijfhout, from the Community

100+

Use this Take 5 safety form to pause and think before starting work. The checklist guides teams to understand the task and procedure, confirm the right tools and PPE, identify hazards such as manual handling, moving parts, energy sources, chemicals, and environmental factors, and assess risk using a simple matrix. If risks remain medium or high, do not proceed. Complete a JSEA or consult a supervisor. Once hazards are eliminated or controlled and induction requirements are met, sign off and proceed.

With SafetyCulture you can

Digitize any process, procedure or policy

Eliminate mistakes made by paper-based processes

Create and share professional reports instantly

Confirm accountability and compliance with a digital log

With SafetyCulture you can

Digitize any process, procedure or policy

Eliminate mistakes made by paper-based processes

Create and share professional reports instantly

Confirm accountability and compliance with a digital log

About author

Community

This community page makes available free workplace checklists and templates created by other users within the SafetyCulture community. SafetyCulture has re-published this content and where possible, has credited the original author. SafetyCulture has not verified the accuracy, reliability or suitability of any community content. You agree that your use of any of this content is in accordance with SafetyCulture’s Terms and Conditions.

Template
MAD3 Engineering Take 5 Safety Form
This Take 5 Safety Form by MAD3 Engineering guides workers to pause and think before starting a task. It captures job details and prompts users to confirm understanding of the task and procedure, check that tools are correct and in good condition, and verify required PPE. The form helps identify hazards including manual handling, slips, trips and falls, mechanical and moving parts, moving plant and roads, and multiple energy sources such as electricity, water, hydraulic, gas, chemical, steam and gravity. It also considers environmental and structural hazards, chemicals, biological risks, radiation, asbestos and dangerous animals. A risk matrix supports assessment, with clear stop work guidance when risk is high. The checklist then focuses on managing changes, ensuring hazards are eliminated or controlled and that PPE, site induction and sign in are complete before proceeding, followed by a signature to authorize work.
by Nathan Jansen van Doorn, from the Community
Downloads: 20+
Get
Template
OZEX Take 5 Inspection
A concise Take 5 checklist designed to pause before work and think through the task. Confirm procedures, permits, training, PPE, and planning; identify hazards like energy isolation, slips, trips, weather, ergonomics, and struck-by risks. Complete a simple risk matrix for likelihood and severity, list controls, and determine whether to proceed, proceed with caution, or stop and inform a supervisor.
by Jono Ride, from the Community
Downloads: 0
Get
Template
STOP Take 5 Safety Checklist
Use this STOP Take 5 checklist to pause before work, confirm you are fit for duty, understand the task, and verify training, permits, PPE, tools, and emergency readiness. Record job details and location, review hazardous energy sources and controls, and identify hazards above, below, behind, and inside the work area. Document risks and confirm controls reduce exposure to ALARP. Sign onto the relevant task risk assessment or procedure, then proceed once hazards are controlled. Designed for mining and heavy industry but adaptable to any high risk site.
by David Richards, from the Community
Downloads: 0
Get
Template
Take 5 Safety and Environment Checklist
This Take 5 safety and environment checklist helps workers pause before starting a job to identify hazards, confirm permit-to-work requirements, and plan controls. It guides users to stop and think through the task, review training, tools, PPE, and documentation, consider common hazards (slips, falls, energy sources, chemicals, mobile plant, environmental impacts), assess risk, and implement changes before proceeding. It supports JSEA and permit decisions and is suitable for industrial and manufacturing sites. Adapt to your operations and local regulations before use.
by Mark Franke, from the Community
Downloads: 20+
Get

MAD3 Engineering Take 5 Safety Form

This Take 5 Safety Form by MAD3 Engineering guides workers to pause and think before starting a task. It captures job details and prompts users to confirm understanding of the task and procedure, check that tools are correct and in good condition, and verify required PPE. The form helps identify hazards including manual handling, slips, trips and falls, mechanical and moving parts, moving plant and roads, and multiple energy sources such as electricity, water, hydraulic, gas, chemical, steam and gravity. It also considers environmental and structural hazards, chemicals, biological risks, radiation, asbestos and dangerous animals. A risk matrix supports assessment, with clear stop work guidance when risk is high. The checklist then focuses on managing changes, ensuring hazards are eliminated or controlled and that PPE, site induction and sign in are complete before proceeding, followed by a signature to authorize work.

by Nathan Jansen van Doorn, from the Community

20+

Get

Template

OZEX Take 5 Inspection

A concise Take 5 checklist designed to pause before work and think through the task. Confirm procedures, permits, training, PPE, and planning; identify hazards like energy isolation, slips, trips, weather, ergonomics, and struck-by risks. Complete a simple risk matrix for likelihood and severity, list controls, and determine whether to proceed, proceed with caution, or stop and inform a supervisor.

by Jono Ride, from the Community

Get

Template

STOP Take 5 Safety Checklist

Use this STOP Take 5 checklist to pause before work, confirm you are fit for duty, understand the task, and verify training, permits, PPE, tools, and emergency readiness. Record job details and location, review hazardous energy sources and controls, and identify hazards above, below, behind, and inside the work area. Document risks and confirm controls reduce exposure to ALARP. Sign onto the relevant task risk assessment or procedure, then proceed once hazards are controlled. Designed for mining and heavy industry but adaptable to any high risk site.

by David Richards, from the Community

Get

Template

Take 5 Safety and Environment Checklist

This Take 5 safety and environment checklist helps workers pause before starting a job to identify hazards, confirm permit-to-work requirements, and plan controls. It guides users to stop and think through the task, review training, tools, PPE, and documentation, consider common hazards (slips, falls, energy sources, chemicals, mobile plant, environmental impacts), assess risk, and implement changes before proceeding. It supports JSEA and permit decisions and is suitable for industrial and manufacturing sites. Adapt to your operations and local regulations before use.

by Mark Franke, from the Community

20+

Get

Take 5 Safety Form

About author

You might also like

MAD3 Engineering Take 5 Safety Form

OZEX Take 5 Inspection

STOP Take 5 Safety Checklist

Take 5 Safety and Environment Checklist

You might also like

MAD3 Engineering Take 5 Safety Form

OZEX Take 5 Inspection

STOP Take 5 Safety Checklist

Take 5 Safety and Environment Checklist