Risk Assessment and Safety Plan

Risk Assessment and Safety Plan

In planning a famil it is critical to assess the health and safety risks to famil participants (including hosts), and to ensure that all practicable measures are taken to mitigate the identified risks (if they cannot be eliminated). Please review and complete the following table to ensure that risks are minimised in undertaking a famil and safety measures are identified.

HOW TO USE THIS FORM

If you are planning(‘the planner’) and planning the famil itinerary, please:

1.Review the Participant Information Form and ensure the planned activities meet the famil objective and accommodate identified constraints or limitations.

2.Complete the first three areas of the table (‘action or activity’, ‘identified risks’ and ‘safety measures taken/plan’) for all activities identified in the itinerary. Please refer to the matrix that is provided to assist you with identifying safety measures.

3.Ensure that this form is completed and authorised by the participating RTOs (or other parties).

If you are booking the famil itinerary activities (‘the booker’) e.g., accommodation, transport and tourism activities, please:

1.Ensure that you complete the ‘evidence cited’ box, please refer to the matrix that is provided to assist you with identifying safety measures and criteria in making a booking decision.

2.Identify yourself as the ‘PCBU’ (Person Conducting a Business or Undertaking) e.g., RTO/IBO etc.

3.Provide your signature at the bottom of the form.

4.In most instances the RTOis the ‘booker’.

SECTION 1.FAMIL PLANNING INFORMATION

FAMIL NAME: / FAMIL DATE PERIOD
START DATE OF FAMIL IN NZ:
LAST DAY OF FAMIL IN NZ:
PLANNER NAME:
EMAIL ADDRESS:
CONTACT PHONE NUMBER: / NAME OF ORGANISATION PLANNING THE FAMIL:

SECTION 2. RISK ASSESSMENT AND SAFETY PLAN

ACTION OR ACTIVITY
(Planner to complete) / IDENTIFIED RISK
(Planner to complete) / SAFETY MEASURES TAKEN/PLAN
(Planner to complete) / EVIDENCE CITED
(Booker to complete) / PCBU NAME:
(Booker to complete)
Staying at accommodation / Accident or injury whilst at the accommodation /

• e.g., Selected accommodation provider is on the authorised supplier list

/ e.g., ABC Hotel is a Qualmark and regulated operator as assessed on the respective sites / e.g., Rotorua RTO
Bungy jump / Accident or injury whilst undertaking bungy /

• Selected provider is Qualmark licenced.

/ AJ Hackett selected. QM licence cited on the Qualmark list / e.g. DQ RTO

SECTION 3. AUTHORISATION

Please type your name below or insert your electronic signatureauthorising the information you have provided on behalf of your PCBU.

Planner Authorisation of Risk Assessment and Safety Plan ______

Identified PCBU Signature ______Organisation______

Identified PCBU Signature ______Organisation______

Identified PCBU Signature ______Organisation______

Identified PCBU Signature ______Organisation______

Identified PCBU Signature ______Organisation______

Identified PCBU Signature ______Organisation______

Identified PCBU Signature ______Organisation______

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