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By signing you are stating the following! <br />I know the hazards: <br />You have been involved in the Tailgate <br />Safety Meeting and understand the <br />hazards and risk control actions <br />associated with each task you are <br />about to perform. <br />You understand the permit to work <br />requirements applicable to the work <br />you are about to perform (if it <br />includes permitted activities). <br />You are aware that no tasks or work <br />(that is not risk-assessed) is to be <br />performed. <br />You also are aware of your obligation <br />to 'Stop any Unsafe Work' <br />WORKERS <br />I arrived and departed fit for duty: <br />You are physically and mentally <br />fit for duty. <br />You are not under the influence <br />of any type of medication, drugs <br />or alcohol that could affect your <br />ability to work safely. <br />You are aware of your <br />responsibility to bring any <br />illness, injury (regardless of <br />where or when it occurred) or <br />fatigue issue you may have to <br />the attention of the site <br />supervisor or PM. <br />You signed out uninjured unless <br />you have otherwise informed <br />the site supervisor or PM. <br />STOP WORK AUTHORITY <br />I will STOP the work any time anyone <br />is concerned or uncertain about <br />safety. <br />I will STOP the work if anyone <br />identifies a hazard or additional <br />mitigation not recorded on the JSA's. <br />I will be alert to any changes in <br />personnel, conditions at the work site <br />or hazards not covered by the original <br />JSA's. <br />If it is necessary to STOP THE WORK, <br />I will reassess the task, hazards and <br />mitigations; and then amend the JSA's <br />as needed. <br />Name: <br /> <br />T-Fit Time in Fit Time out Name: Fit Time in Fit Time out <br />0 <br />0 <br />0 0 0 <br />0 <br />0 0 0 0 <br />0 0 0 El <br />0 0 0 0 <br />0 0 0 <br />0 0 0 0 <br />0 0 0 0 <br />0 0 0 <br />0 0 0 <br />0 0 <br />H&S Departi-nent/Daity Tailgate 3arety Meeting F or m/ 2 01 7