Information

  • Document No.

  • Audit Title

  • Location / Project Name

  • Observer's Name

  • Observee's Name

  • Conducted on

Personal Protective Equipment

  • 1. Hearing Protection (e.g., ear plugs)

  • 2. Head Protection (e.g., hard hat)

  • 3. ANSI-rated Eye Protection (e.g., safety glasses)

  • 4. Hand Protection (e.g., Kevlar gloves)

  • 5. Foot Protection (e.g., safety shoes)

  • 6. Respiratory Protection

  • 7. Fall Protection Inspected (e.g., harness)

  • 8. ANSI-rated Reflective Vest/High-visibility Clothing

  • 9. Other (specify)

  • Add media

Body Use and Positioning

  • 10. Correct Body Use and Positioning When Lifting/Pushing/Pulling

  • 11. Pinch Points/Moving Equipment - Hands/Body Clear

  • 12. Mounts/Dismounts Using Three Points of Contact

  • 13. Other (specify)

  • Add media

Work Environment

  • 14. Work/Walk Surface Free of Obstructions (e.g., tripping hazards)

  • 15. Housekeeping/Storage

  • 16. Defined and Secured (e.g., warning devices, barricades, cones, flags, etc.)

  • 17. Suspended Load, Swing Radius, and Lift Area is Barracaded

  • 18. Safety Shut-down Devices

  • 19. Proper Storage and Labeling/Disposal of Sample and Waste Materials

  • 20. Cylinders Stored Upright, Secured, and Caps in Place

  • 21. Manhole/Vault Inspected for Hazards

  • 22. Other (specify)

  • Add media

Operating Procedures

  • 23. Job Planning Discussed During Tailgate Meeting (e.g., HASP, JSAs, etc. reviewed)

  • 24. Fire Extinguishers Accessible and Inspections Current

  • 25. Work Permit/Authorization to Work (e.g., Hot, Cold, LOTO, Confined Space)

  • 26. JSA Reviewed and Followed

  • 27. Hazard Assessment Conducted - Hazard Hunt

  • 28. Interfaces with Other Functions (awareness with other personnel on site)

  • 29. Operators Looking Behind Prior to Backing Up

  • 30. Operators Wearing Seat Belts While Operating Equipment

  • 31. Subsurface Structures Identified

  • 32. Proper Trench Protective Equipment in Place

  • 33. Adequate Egress is Available for Excavation and Trench (within 25 ft. if depth is ≥4 ft.)

  • 34. All Materials Set Back at Least 2 Feet from Edge of Trench/Excavation

  • 35. Other (specify)

  • Add media

Tools/Equipment

  • 36. Hand Tools (proper equipment selection, condition, and use)

  • 37. Power Tools (proper equipment selection, condition, and use)

  • 38. Equipment, Including Heavy (proper equipment selection, condition, and use)

  • 39. Hoses Inspected

  • 40. Required Monitoring Equipment Calibrated and Used

  • 41. Ladders Set Up Correctly and Inspected

  • 42. Right Tools for the Job are Available and in Good Condition - No Fixed Open-blade Knives (FOBKs)

  • 43. Other (specify)

  • Add media

Quality Control

  • 44. Are sampling procedures/workplan/SAP/QAPP available on site?

  • 45. Are TRC SOPs available and being followed? (Observer should spot-check specific SOP tasks.)

  • 46. Are proper forms and field notes being used and collected?

  • 47. Is all equipment being calibrated as required?

  • 48. Are sample containers properly labeled and stored?

  • 49. Are proper QC samples (e.g., duplicate, MS, trip blanks, temperature blanks) being collected/used and being collected/used properly?

  • 50. Are proper decontamination procedures occuring?

  • 51. Is the chain-of-custody document properly filled out and provided with the samples?

  • 52. Other (specify)

Summary Page

  • Task Observed

  • Description of Task Observed and Background Information

  • Positive Comments

  • Conclusions / Why Questionable Items Occurred.

  • Feedback Session Conducted By:

  • Date / Time:

  • Name of Observee's Supervisor

Questionable Observations / Root Cause Analysis

  • Personal Factor: (1) Lack of skill or knowledge (2) Correct way takes more time/requires more effort (3) Shortcutting standard procedures is rewarded or appreciated (4) In past, did not follow procedures or acceptable practices and no incident occurred

  • Job Factor: (5) Lack of or inadequate operational procedures or work standards (6) Inadequate communication of expectations or work standards (7) Inadequate tools or equipment

  • Questionable Observation #

  • Route Cause Analysis #

  • Solution(s) to Prevent Potential Incident from Occuring

  • Person Responsible

  • Agreed Due Date

  • Date Completed

  • Questionable Observation #

  • Route Cause Analysis #

  • Solution(s) to Prevent Potential Incident from Occurring

  • Person Responsible

  • Agreed Due Date

  • Date Completed

  • Questionable Observation #

  • Route Cause Analysis #

  • Solution(s) to Prevent Potential Incident from Occurring

  • Person Responsible

  • Agreed Due Date

  • Date Completed

  • Questionable Observation #

  • Route Cause Analysis #

  • Solution(s) to Prevent Potential Incident from Occurring

  • Person Responsible

  • Agreed Due Date

  • Date Completed

  • Questionable Observation #

  • Route Cause Analysis #

  • Solutions(s) to Prevent Potential Incident from Occurring

  • Person Responsible

  • Agreed Due Date

  • Date Completed

  • Results of Verification (were solutions done?) and Validation (were solutions effective?)

  • Reviewed by (Supervisor):

  • Date:

  • Approved by (Practice Safety Leader):

  • Date:

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.