Information

Personnel Section

  • Employee

  • Prepared by

  • Location

  • Conducted on

  • Document No.

Reason for Observation

  • Job Performance Review

  • New Job Assignment

  • New Employee

  • Other

  • Specify

Skill in Methods

  • Not Observed (NOB) = Activity not observed
    Below (B) = Somewhat clumsy, fumbles, hesitations (loses time)
    Meet (M)= Steady, average (neither gains or loses time)
    Exceed (E) = Safely reduces motion, quick (gains time)

  • Task title

  • 1. Obtains all necessary materials efficiently without delay

  • 2. Uses most direct route to task

  • 3. Completes all necessary steps efficiently

  • 4. Accurately complete all documentation / entries for task

  • 5. Efficiently acquire and log into next task

Performance

Performance Estimate

  • Scoring Performance Estimate
    Below = Less than 0
    Meet = Greater than 0 but less than +10
    Exceed = Greater than +10

    Enter notes on why, by touching category.

  • Skill in Methods

  • Skill characteristics:
    Below = Somewhat clumsy, adds motion, fumbles, hesitation, errors.
    Meet = Follows methods, proficient, consistent, steady, average.
    Exceed = Precise and smooth, quick ensure, reduces motions

  • Effort Level

  • Effort characteristics:
    Below = Slow, not best effort, slow motion
    Meet = Steady, average
    Exceed = Fast, enthusiastic, focused

  • Time Utilization

  • Utilization characteristics:
    Below = Does not try to avoid delay, exceeds delay allowances, stops working to talk
    Meet = Minimizes delay by following the methods. Stays on task.
    Exceed = Eliminates delay by eliminating motion. Always successful at avoiding delay

  • Was this an on standard task?

  • Performance Estimate:

  • Actual Performance:

Safety

Safety

  • Were there any safety concerns observed during this audit?

  • Remember to always be watching for situations that could potentially become safety concerns. Be proactive and make sure we are providing all our employees with the knowledge and equipment to ALWAYS be safe. Safety first!

  • Address safety issues immediately.

  • Select categories that apply.

  • Describe concern

Coachable Moment

Coachable Moment

  • Review Coachable Behavior with associate

    5-Step Coaching Model
    1. Convey positive intent
    2. Describe behavior and actions observed
    3. State impact of desired coachable behavior(s)
    4. Ask associate to respond
    5. Focused discussion on solution

  • Was a Coachable moment observed?

  • Coachable category:

  • Coachable Behavior (Additional notes about employees performance during the observation)

  • Follow-Up required:

  • Planned date for Follow-Up:

  • Associate Signature:

  • Supervisor Signature:

  • Quality Audit by Manager

  • CMO Quality feedback

  • Managers signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.