Title Page

  • Conducted on

  • Prepared by

  • Location
  • Task Description

  • Contract Supervisor

At risk behaviours judged to be of fatality potential shall result in an injury free event case in the incident reporting system (EHSIMS). The Observation Team is responsible for ensuring that this is completed

Safety Work Contact and JSA Audit

Observation Team:

  • Number of people in Observation team

  • Number of people contacted:

  • Please take a photo of the task being undertaken.

Personal Protective Equipment

  • Head, Foot, Eye / Face, Body

  • Mandatory PPE is worn by work group

  • Hand - Available and used as required by JSA

  • Respiratory - Available and used as required by JSA

  • Hearing - Available and used where mandatory

Procedure Related

  • Tag / Lock / Isolation - Personal Danger Tag is attached correctly

  • Secure Work - Crew agrees with Contents of SWI & JSA

  • Job Prep Hazard - SWI & JSA available and being used

  • Chemical Usage - MSDS readily available

Working Environment Category 3

  • Housekeeping / Storage - Work area free of housekeeping hazards

  • Barricades / Exclusion Zones - Reason for installation is on attached tag

  • Facility condition / Working conditions - Aware of housekeeping responsibilities

Tools and Equipment

  • Selection - Adequate and suitable for task being performed

  • Condition - In good order and checked prior to use

  • Use - Able to explain safety features / controls

Body use and Position

  • Line of Fire - Defensive working positions adopted

  • Pinch Points - Mechanical aids available and used

  • Lifting / Pushing / Pulling / Carrying - Able to explain correct lifting techniques

  • Walking / Climbing - Aware of hazards on floors, stairs and wet surfaces

  • Stable/Secure/Extended - Correct body position during task performance

Mobile Equipment

  • Condition - Pre-Start Checks completed daily

  • Enter / Exit - Three points of contact used

  • Pedestrian Segregation - 50m Rule, radio or eye contact used

JSA Audit

  • Is the JSA readily available at the workface for any persons entering the work area?

  • Has the JSA been reviewed/updated and signed onto today?

  • Have all personnel engaged in the task signed onto the JSA?

  • Has the JSA been reviewed and signed by the CHC Supervisor?

  • Has the JSA been signed off by the client representative?

  • Does the workgroup have a clear understanding of the task and associated hazards?

  • Does the JSA identify ‘Permit To Work’ requirements associated with the task?

  • Is an exclusion zone erected as per site requirements and are all entry points signed posted?

  • Does the JSA adequately reflect the task being performed?

  • Has the task been appropriately Risk Assessed?

  • Are the JSA task steps being followed by the work group?

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

  • Is the workgroup wearing all the required PPE for the task?

  • Have STOP points been identified in the JSA?

  • Is the workgroup working with the correct ergonomics techniques in place?

  • Have the critical controls been documented and implemented?

  • Did you need to STOP the task or implement any corrective actions? YES / NO (detail actions above)

  • Are there any follow-up actions required? YES / NO Details:-

Sign off

  • Name

  • Additional personnel involved

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.