WORKSAFE VICTORIA / SAFETY MANAGEMENT SYSTEMS GUIDE FOR LABOUR HIRE AGENCIES (2nd Edition, October 2005).
AGREED ACTIONS RECORD
Who uses this form?
Labour-hire agency.
Purpose?
To ensure that everyone agrees what needs to be done to manage safety.
What should happen
Copies of this should be given to the host employer. Keep the original copy at the labour-hire agency in a file with the host employer’s name on it. Take a copy on visits to the host
employer to monitor progress against the agreed actions.
1. HOST EMPLOYER DETAILS
Name of host employer:
Location (or address):
Name Surname
Date:
Location or address of job
Contact person at host employers:
Telephone:
Corrective action arising from:

Job safety assessment

Worksite inspection

01/01/05
Agency Name
Phone Number
Incident / Hazard / Accident report

Other
2. CORRECTIVE ACTIONS You should negotiate agreement with the host employer for all corrective actions.
ACTION NO:
HAZARD
INTERIM MEASURE REQUIRED?
PERSON RESPONSIBLE
AGREED
COMPLETION
DATE
ACTUAL
COMPLETION
DATE
CORRECTIVE ACTIONS
Page 1 of 2
WORKSAFE VICTORIA / SAFETY MANAGEMENT SYSTEMS GUIDE FOR LABOUR HIRE AGENCIES (2nd Edition, October 2005).
AGREED ACTIONS RECORD
3. INTERIM CONTROL MEASURE (Things you will do to reduce the risk of injury when you can’t immediately control the risk by using an engineering solution)
ACTION NO:
DESCRIBE THE INTERIM MEASURE TO BE PROVIDED
PERSON RESPONSIBLE
AGREED
COMPLETION
DATE
ACTUAL
COMPLETION
DATE
DESCRIBE THE INTERIM MEASURE TO BE PROVIDED
4. AGREEMENT WITH CORRECTIVE ACTIONS
Consultant
Signature:
Full Name (CAPITALS PLEASE)
Host employer
Signature:
Full Name (CAPITALS PLEASE)
NAME SURNAME
NAME SURNAME
Date:
Date:
01/01/05
01/01/05
5. SIGN OFF UPON COMPLETION OF CORRECTIVE ACTIONS
Consultant
Signature:
Full Name (CAPITALS PLEASE)
NAME SURNAME
Date:
Host employer
Signature:
Full Name (CAPITALS PLEASE)
NAME SURNAME
Date:
01/01/05
01/01/05
Please send a copy of this form to the host employer and keep a copy in your files.
2
Page 2 of 2