Information
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Conducted on
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Audit Title (Observer's initials - Area Observed - MM/DD/YY)
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Area Observed
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Document No. (Automatic)
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Prepared by
Area Observation
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Conditions Observed (PPEs, Body Position, Tools and Equipment, Work Environment, Procedures)
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Recommendations for Continuous Improvement:
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Actions taken:
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Work Order #:
Acknowledgement
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Observer:
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Department Representative:
Behavioral Based Observation
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How do you report an incident?
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Was the question answered satisfactorily?
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When do you report an incident?
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Was the question answered satisfactorily?
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Who do you contact in the event of an incident/accident/emergency?
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Was the question answered satisfactorily?
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Who are the representatives on the safety committee?
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Was the question answered satisfactorily?
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Where is the closest fire extinguisher?
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Was the question answered satisfactorily?
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Where is the nearest exit? What is the alternate exit?
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Was the question answered satisfactorily?
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Describe the correct body position for your job task
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Was the question answered satisfactorily?
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Where are the lock-out points on your machine?
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Was the question answered satisfactorily?
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Which lines or hoses, in your area, are under pressure?
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Was the question answered satisfactorily?
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Which tools do you need? Do you have them?
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Was the question answered satisfactorily?
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What PPEs are required for the task you are doing?
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Was the question answered satisfactorily?
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Where are the housekeeping tools in your area?
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Was the question answered satisfactorily?
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What is a hot work permit?
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Was the question answered satisfactorily?
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Where are the chemicals stored?
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Was the question answered satisfactorily?
Acknowledgement
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Observer
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Person Observed
