CHC Management Contact

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Personal Protective Equipment

• Head, foot, eye / face, body

  Yes

  No

  N/A

• Hand

  Yes

  No

  N/A

• Respiratory

  Yes

  No

  N/A

• Hearing

  Yes

  No

  N/A

Procedure Related

• Tag / Lock / Isolation

  Yes

  No

  N/A

• Secure work

  Yes

  No

  N/A

• Job Prep Hazard

  Yes

  No

  N/A

• Chemical usage

  Yes

  No

  N/A

Working Environment

• Housekeeping / Storage

  Yes

  No

  N/A

• Barricades / Exclusion Zones

  Yes

  No

  N/A

• Facility condition / Working conditions

  Yes

  No

  N/A

Tools and Equipment

• Selection

  Yes

  No

  N/A

• Condition

  Yes

  No

  N/A

• Use

  Yes

  No

  N/A

Body Use and Position

• Line of fire

  Yes

  No

  N/A

• Pinch Points

  Yes

  No

  N/A

• Lifting / Pushing / Pulling / Carrying

  Yes

  No

  N/A

• Walking / Climbing

  Yes

  No

  N/A

• Stable / Secure / Extend

  Yes

  No

  N/A

Mobile Equipment

• Condition

  Yes

  No

  N/A

• Enter / Exit

  Yes

  No

  N/A

• Pedestrian Segregation

  Yes

  No

  N/A

• Has a JHA / SWI been developed for the task and available at the workface in such a manner for the work team or persons entering the area to gain ready access.

  Yes

  No

  N/A

• Have all personnel engaged in the task signed onto the JHA.

  Yes

  No

  N/A

• Has the JHA been reviewed and signed by the job supervisor.

  Yes

  No

  N/A

• Does the JHA identify permit to work requirements associated with the task.

  Yes

  No

  N/A

• Does the JHA adequately reflect the task being performed?

  Yes

  No

  N/A

• Has the JHA been appropriately risk assessed?

  Yes

  No

  N/A

• Are the JHA task steps being followed?

  Yes

  No

  N/A

• Have all potential hazards been identified (detail major hazards that have not been accounted for)

  Yes

  No

  N/A