Dammers Form

SUBCONTRACTOR SAFETY DECLARATION & RISK ASSESSMENT
Project Name
Subcontractor / Company Name*
Contact Person*
Phone / Email*
Ship Name*
Location*
Date of work*

MonthDayYear
Date
Detail the work that will be undertaken:*
Risk assessment :*

Work at heightElectricalConfined spaceNoise / Hearing damageHot workLifting operationsMechanicalOther
If "Other" please give details:
An inspected Safety Harness must be worn at all times when working at height
The following Personal Protective Equipment and Control measures must be implemented:

Safety bootsHard hatSafety glassesGlovesHigh visibility clothingFirst aid controlsBarriersBreathing apparatusFace shieldProtection from falling objectsFire extinguishersIsolate fire alarmSafety harnessHearing protectionOverallsRadio communicationIsolate electricsNo high windsArea clear of wasteItem defect checked before useLadder footed at all timesGas chemist certificateGas detector
Other PPE used:
Lift plan and risk assessment completed*

YesNo
Do you require the lock out of machinery ?*

YesNo
Do you require ventilation?*

YesNo
Means of Access:*

ScaffoldMobile Elevated Work Platform (MEWB)LaddersCrawl BoardsOtherNone Required
If "Other" please give details:*
(Tick to Confirm)*

Confirm that ladders being used have been defect checked prior to use, will not be used in adverse weather conditions and will be footed at all times by a second man.
Select the Hazards introduced by the Works:*

FireFall from HeightElectrocutionExplosionEntanglement of LimbsOther
If "Other" please give details:*
Specify Safety Precautions being taken:*

Safety Training and Certification

	Completed / Training received	Certificate Available?
HSE (Health, Safety, and Environment) or equivalent
Working at Heights
6S Principles
Confined Space Entry
First Aid / Emergency Response
Firefighting Awareness

I, the undersigned, confirm:
- Full awareness of all safety and operational risks.
- That I have been trained, skilled, and knowledgeable to safely perform my tasks
- Commitment to wearing PPE and following all applicable procedures.
- That all staff under my supervision have been briefed accordingly.
- Full compliance with Dammers' Life Saving Rules.
- All equipment such used must be certified and within their valid inspection period.
- Vehicles and personnel must be insured in accordance with applicable laws and regulations.
This safety declaration is part of Dammers Shipagencies’ ISO 9001 (Quality Management) compliance procedures.
Name*

First NameLast Name
Company Name:*
Date*

DayMonthYear
DateHourMinutesAM/PM Option
Signature*

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SUBCONTRACTOR SAFETY DECLARATION & RISK ASSESSMENT