Title Page

  • Conducted by

  • Location
  • Conducted on

  • Instruction: any item identified as "no" or at risk requires a documented action. All Reports must be kept as evidence.

Readiness of People

  • Stopping work

  • Rearranging task or job

  • Changing tools

  • Applying Lockout Tagout

  • Adjusting PPE

Position of People

  • Striking against

  • Caught in-between

  • Inhaling (chemical, dust, etc.)

  • Absorbing (chemical)

  • Electrical

  • Hazardous energy

  • Falling different level

  • Slip, trip, fall same level

  • Struck by

  • Other:

PPE personal protective equipment right for task and properly fitted, inspected and used

  • Head

  • Eyes

  • Face (face-shield used with safety glasses)

  • Ears (muffs, foam or custom ear plugs)

  • Respiratory system (seal, dust mask, half- or full face respirator, cartridge type -duration of use, all bands in place, clean shaven)

  • Hands and arms (glove type, size, cut-proof sleeves, no jewelry, sleeves)

  • Feet and legs (boot or shoe type, pants)

  • Other PPE:

Tools and/or Equipment

  • Right for the task or job

  • Used correctly

  • In safe good condition

  • Harness, SRL etc. Inspected & in good condition

  • Gloves right for task

  • Ladders, platforms, Barricades, railings in good condition & right for task

  • Warning (signs, alarms, etc.) in place & functional

  • Monitoring and/or measuring equipment in good condition & calibrated

  • Other:

Procedures

  • Has a complete, timely and accurate risk assessment has been completed for all their work tasks and updated when any changes occurred?

  • Does the risk assessment identify all hazards, risk rating and controls and are the controls fully implemented?

  • Other:

6S Orderliness & Tidiness

  • Standard in place & understood

  • Work area organized

  • Well-organized tools

  • Material storage right

  • Stairs/platforms location (controlled access if in pathway)

  • Obstructions (adequate egress/ entrance)

Further Actions

  • Are any other issues identified? (Please give photographic evidence)

  • Inspector Sign Off

  • Person Responsible of Inspected Area Sign Off

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.