Competency Assessment FormFill this in on your phone. Tap the boxes and type in the blanks. What you enter is kept on this phone while you work. When you are done, send it to the safety team, or print it.[ Church name ] church Health & safety competency assessment This form is designed to assess and record the competency of staff and volunteers in health and safety matters. Complete all relevant sections according to the person’s role and responsibilities. Assessment details Field Information Person Being Assessed: Position/Role: Department/Ministry: Assessment Date: Assessor Name: Assessor Position: Assessment Type: InitialAnnual ReviewPost-TrainingPost-Incident Role analysis Primary Responsibilities Main duties and tasks: Health and safety critical activities: Risk exposure level: LowMediumHigh Supervision level: CloseGeneralMinimalIndependent Knowledge assessment General Health & Safety Knowledge Topic Assessment Method Score/Rating Competent Comments H&S Legislation (HSWA 2015) Written Oral Observation YesNo Church H&S Policies Written Oral Observation YesNo Risk Management Principles Written Oral Observation YesNo Incident Reporting Procedures Written Oral Observation YesNo Emergency Procedures Written Oral Observation YesNo Role-Specific Knowledge Topic Assessment Method Score/Rating Competent Comments Job-Specific Hazards Written Oral Observation YesNo Safe Work Procedures Written Oral Observation YesNo Equipment Safety Written Oral Observation YesNo PPE Requirements Written Oral Observation YesNo Chemical Safety (if applicable) Written Oral Observation YesNo Practical skills assessment Hazard Identification Assessment Task: Identify hazards in the designated work area Hazard Type Identified Correctly Assessed Control Measures Suggested Rating Physical Hazards YesNo YesNo YesNo CNYC Chemical Hazards YesNo YesNo YesNo CNYC Biological Hazards YesNo YesNo YesNo CNYC Ergonomic Hazards YesNo YesNo YesNo CNYC Psychosocial Hazards YesNo YesNo YesNo CNYC Overall Hazard Identification Competency: CompetentNot Yet Competent Risk Assessment Assessment Task: Complete risk assessment for identified hazards Skill Component Demonstrated Quality Rating Likelihood Assessment YesNo ExcellentGoodFairPoor CNYC Consequence Assessment YesNo ExcellentGoodFairPoor CNYC Risk Rating Calculation YesNo ExcellentGoodFairPoor CNYC Control Hierarchy Application YesNo ExcellentGoodFairPoor CNYC Documentation Quality YesNo ExcellentGoodFairPoor CNYC Overall Risk Assessment Competency: CompetentNot Yet Competent Emergency Response Assessment Task: Demonstrate emergency response procedures Emergency Type Procedure Known Response Appropriate Speed of Response Rating Fire Emergency YesNo YesNo Fast Adequate Slow CNYC Medical Emergency YesNo YesNo Fast Adequate Slow CNYC Evacuation YesNo YesNo Fast Adequate Slow CNYC Incident Reporting YesNo YesNo Fast Adequate Slow CNYC Overall Emergency Response Competency: CompetentNot Yet Competent Behavioral assessment Safety Attitude and Behaviour Behavior Always Usually Sometimes Rarely Never Follows safety procedures Uses PPE correctly Reports hazards and incidents Participates in safety activities Demonstrates safety leadership Challenges to unsafe behaviour Seeks safety information Communication Skills Skill Excellent Good Fair Poor Comments Explains safety concepts Listens to safety concerns Provides safety feedback Documents safety issues Specific competency areas Working with Children (if applicable) Competency Demonstrated Quality Comments Child protection awareness YesNo Excellent Good Fair Poor Age-appropriate supervision YesNo Excellent Good Fair Poor Recognising child safety risks YesNo Excellent Good Fair Poor Emergency response with children YesNo Excellent Good Fair Poor Equipment Operation (if applicable) Equipment Competent Training Required Certification Comments Kitchen equipment YesNo YesNo CurrentExpired Audio/visual equipment YesNo YesNo CurrentExpired Maintenance tools YesNo YesNo CurrentExpired Cleaning equipment YesNo YesNo CurrentExpired Leadership Responsibilities (if applicable) Responsibility Competent Development Needed Comments Team safety leadership YesNo YesNo Safety training delivery YesNo YesNo Incident investigation YesNo YesNo Risk assessment facilitation YesNo YesNo Assessment summary Overall Competency Rating Area Competent Not Yet Competent Comments Knowledge Practical Skills Behaviour and Attitude Communication Role-Specific Requirements Overall Assessment: CompetentCompetent with ConditionsNot Yet Competent Strengths Identified Areas for Improvement Specific Development Needs Development Need Priority Suggested Action Target Date Resources Required High Med Low High Med Low High Med Low Development plan Training Requirements Training Provider Duration Cost Target Date Priority High Med Low High Med Low High Med Low Mentoring/Coaching Plan Mentor Assigned: Coaching Focus Areas: Meeting Schedule: Progress Review Date: ** Supervision Arrangements Supervision Level Required: CloseGeneralMinimalIndependent Supervisor: Supervision Frequency: Review Date: ** Sign-offs Assessor Declaration I confirm that this assessment has been conducted fairly and accurately reflects the person’s current competency level. Assessor Name: Signature: Date: ** Qualifications: Person Assessed I acknowledge that: - This assessment has been explained to me - I understand the results and development plan - I agree to undertake the recommended development activities - I will seek help when needed Name: Signature: Date: Supervisor Approval I approve this assessment and the associated development plan. Supervisor Name: Signature: Date: Review schedule Next Assessment Due: Interim Review Date: Development Plan Review: File Location: Record Updated By: Date: Finished?Website Your name *Send to the safety teamPrint or save as PDF Clear everything