Soakhole Cleaning Audit Form

Soakhole Cleaning Audit

(Version 0.1) Black Auckland Council Logo

Audit Location Details

Date:
Site Address:
Work Order Number:		Weather:
Region:
Main Contractor:		Subcontractor:
Audit Representatives
Contractor Rep:		Council Rep:
Vehicle Information
Vehicle Registration:		Vehicle Condition:	1 2 3 4 5
Vehicle Registration Other:
Certificate of Fitness Current?	Yes No	COF Expiry Date:
Vehicle Registration Current?	Yes No	Registration Expiry Date:
Driving in Accordance with Road Rules?	Yes No	Standard of Driving Observed:	1 2 3 4 5
Health and Safety
Induction Completed?	Yes No	Standard of Induction Given:	1 2 3 4 5
Hazard ID Completed?	Yes No	Standard of Hazard ID Completed:	1 2 3 4 5
Site Emergency Plan:	Yes No	Standard of Site Safety Plan:	1 2 3 4 5
PPE Being Used:	Hardhat Hi-Viz Safety Boots Glasses Gloves Hearing Pro. Masks	PPE Used Other:
		All PPE Identified:	1 2 3 4 5
		PPE Identified being used?:	1 2 3 4 5
Spill Kits Available On Vehicle?	Yes No N/A	Spill Kit Fully Stocked:	1 2 3 4 5
Fire Extinguisher Available In Vehicle?	Yes No N/A
Extinguisher Currently Certified?	Yes No N/A
General Comments:	Corrective Actions

COVID Safety Requirements
Current Covid Alert Level	1 1.5 2 2.5 3 4
Covid PPE Available	Mask Gloves Hand Sanitiser
Traffic Management
Traffic Management Plan:		TMP Plan Number:
STMS Available:		TMP Setout As Per Plan:	1 2 3 4 5
Vehicle Signage as per TMP?:	Yes No	Condition of Vehicle Signage:	1 2 3 4 5
General Comments:	Corrective Actions

Standard of Soakhole Cleaning
All Debris Removed from Soakholes?	Yes No	Standard of Cleaning:	1 2 3 4 5
Soakholes Cleaned in Accordance with Council Requirements?	Yes No	Meets Council Requirements?:	1 2 3 4 5
Are Faults Being Correctly Reported?	Yes No	Accuracy of Fault Reporting:	1 2 3 4 5
Total Number of Soakholes Inspected:		Number of Soakholes Not to Standard:
General Comments:	Corrective Actions

Confined Spaces/Working At Height Planning a Confined Space Entry
Permits Being Used?	Yes No N/A	Permit Information Correct?	1 2 3 4 5
Gas Detector Certification Current?	Yes No N/A
Tripod Certification Current?	Yes No N/A	Safety Equipment Certifications?	1 2 3 4 5
Harness Certification Current?	Yes No N/A	Safety Equipment Condition?	1 2 3 4 5
Work exceeding 5m in depth?	Yes No N/A
If Yes, is Work Safe Notification onsite?	Yes No N/A
Worksafe Hazardous Works Notification Form
Fall/CSE Area Protected? (barrier,tape,fence)	Yes No N/A	Standard of Area Protection?	1 2 3 4 5
General Comments:	Corrective Actions

Audit Result
Fail Low Pass Pass High Pass Excep
Contractor Signature:	Engineer Signature:

Date:	Date:

Soakhole Cleaning Audit

Audit Location Details

Audit Representatives

Vehicle Information

Health and Safety

COVID Safety Requirements

Traffic Management

Standard of Soakhole Cleaning

Confined Spaces/Working At Height

Audit Result