Information

  • Client / Site

  • Prepared by

  • Conducted on

  • Location
  • Document No.

  • Person(s) Involved with Task

  • Employee
  • Full Name

  • Activity/task

1.0 Documentation i.e. permits, mods, etc.

  • 1.1 Permit checked and signed off

  • What did the person say when asked why?

  • Solution?

  • Resolved

  • 1.2 JHA (eg signed and completed)

  • What did the person say when asked why?

  • Solution?

  • Resolved

  • 1.3 Take 5

  • What did the person say when asked why?

  • Solution?

  • Resolved

  • 1.4 Follows written take 5 and JHA

  • What did the person say when asked why?

  • Solution?

  • Resolved

2.0 Standards and procedures

  • 2.1 Sources of energy controlled

  • What did the person say when asked why?

  • Solution?

  • Resolved

  • 2.2 Attached lock and tag to isolation points

  • What did the person say when asked why?

  • Solution?

  • Resolved

3.0 Position of people/mobile equipment

  • 3.1 Avoid lines of fire (fingers, hands and body)

  • What did the person say when asked why?

  • Solution?

  • Resolved

  • 3.2 Three points of contact when climbing or descending

  • What did the person say when asked why?

  • Solution?

  • Resolved

  • 3.3 Avoid cramped or over extended posture

  • What did the person say when asked why?

  • Solution?

  • Resolved

4.0 Ergonomics

  • 4.1 Bends knees when lifting

  • What did the person say when asked why?

  • Solution?

  • Resolved

  • 4.2 Load close to the body

  • What did the person say when asked why?

  • Solution?

  • Resolved

  • 4.3 Strong spine when lifting

  • What did the person say when asked why?

  • Solution?

  • Resolved

  • 4.4 Turns with feet and not their back

  • What did the person say when asked why?

  • Solution?

  • Resolved

  • 4.5 Lifts with their legs

  • What did the person say when asked why?

  • Solution?

  • Resolved

  • 4.6 Mechanical aids/team lifting

  • What did the person say when asked why?

  • Solution?

  • Resolved

5.0 Tools and equipment

  • 5.1 Correct for task

  • What did the person say when asked why?

  • Solution?

  • Resolved

  • 5.2 Used correctly/safely

  • What did the person say when asked why?

  • Solution?

  • Resolved

  • 5.3 Seat belts

  • What did the person say when asked why?

  • Solution?

  • Resolved

  • 5.4 Pre start inspection and completed log book

  • What did the person say when asked why?

  • Solution?

  • Resolved

  • 5.5 Drives to road conditions

  • What did the person say when asked why?

  • Solution?

  • Resolved

  • 5.6 Vehicle parked correctly (reversed/chocked)

  • What did the person say when asked why?

  • Solution?

  • Resolved

6.0 Housekeeping/area conditions

  • 6.1 Work area tidy

  • What did the person say when asked why?

  • Solution?

  • Resolved

  • 6.2 Barricades and signs

  • What did the person say when asked why?

  • Solution?

  • Resolved

  • 6.3 Hazardous materials stored/handled/transported/used/disposed correctly

  • What did the person say when asked why?

  • Solution?

  • Resolved

7.0 Personal protective equipment (PPE)

  • 7.1 Head

  • What did the person say when asked why?

  • Solution?

  • Resolved

  • 7.2 Eye and face

  • What did the person say when asked why?

  • Solution?

  • Resolved

  • 7.3 Hearing

  • What did the person say when asked why?

  • Solution?

  • Resolved

  • 7.4 Respiratory

  • What did the person say when asked why?

  • Solution?

  • Resolved

  • 7.5 Hand

  • What did the person say when asked why?

  • Solution?

  • Resolved

  • 7.6 Sleeves rolled down and fastened

  • What did the person say when asked why?

  • Solution?

  • Resolved

  • 7.7 Foot

  • What did the person say when asked why?

  • Solution?

  • Resolved

  • 7.8 Fall arrest/restraint

  • What did the person say when asked why?

  • Solution?

  • Resolved

  • 7.9 Sun/heat protection

  • What did the person say when asked why?

  • Solution?

  • Resolved

Positive feedback comments

  • Comments

  • Supervisor Signature

Email to site safety department.

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