• Building

  • Date/Time

  • Employee name

  • Task being completed.


  • Are they wearing proper foot protection (safety shoes)?

  • Are they wearing the proper hand protection?

  • Are they wearing the proper eye protection?

Equipment usage

  • Mobile Equipment- was it inspected before use?

  • Forklift- was operator checklist completed before use?

  • Forklift - was forklift operated safely?

  • Vehicle operation - was operator checklist completed before use?

  • Vehicle operation - was vehicle operated safely?

  • Tools - was tool inspected before use?

  • Tools - was tool used correctly?


  • Lifting/carrying/pulling/pushing:
    Body movement


  • Was JSA reviewed prior to completing task?

  • Was Take 5 completed before completing task?

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. Any ratings or scores displayed in our Public Library have not been verified by SafetyCulture for accuracy. Users of our platform may provide a rating or score that is incorrect or misleading. You should independently determine whether the template is suitable for your circumstances. You can use our Public Library to search based on criteria such as industry and subject matter. Search results are based on their relevance to your search and other criteria. We may feature checklists based on subject matters we think may be of interest to our customers.