Employee Field Engagement Form- MPS

• Prepared by

• Name of employee(s) engaged

• Conducted on

  Date

• Shift

  Days

  Nights

• Day in rotation

  Select 1 2 3 4 5 6 7 8

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8

• Crew

  Select Crew 1 Crew 2 Crew 3 Crew 4 Straight Days Other

  • Crew 1
  • Crew 2
  • Crew 3
  • Crew 4
  • Straight Days
  • Other

• Employee department

  Select Ancillary Contractor Dewatering Maintenance Mill Mine Ore process Security Site admin Tech Services

  • Ancillary
  • Contractor
  • Dewatering
  • Maintenance
  • Mill
  • Mine
  • Ore process
  • Security
  • Site admin
  • Tech Services

• Which Maint group

  Select Fixed Electrical Mobile

  • Fixed
  • Electrical
  • Mobile

• Which group

  Select Dispatch IT Operations

  • Dispatch
  • IT
  • Operations

• Which group

  Select Met lab Pads Plants Refinery

  • Met lab
  • Pads
  • Plants
  • Refinery

• Which group

  Select General store Golf course Day care Hadley Maintenance Warehouse/Purchasing Clinic

  • General store
  • Golf course
  • Day care
  • Hadley Maintenance
  • Warehouse/Purchasing
  • Clinic

• Which group

  Select Accounting CI Environmental HR Management Safety

  • Accounting
  • CI
  • Environmental
  • HR
  • Management
  • Safety

• Which group

  Select Assay lab Projects Survey Sampling Geotech Hydrology Geology Exploration

  • Assay lab
  • Projects
  • Survey
  • Sampling
  • Geotech
  • Hydrology
  • Geology
  • Exploration

• Contracting group name

• Please select level of engagement

  Select Permit to work Field conversation/engagement Job task observation Training observation CRM engagement GAPS

  • Permit to work
  • Field conversation/engagement
  • Job task observation
  • Training observation
  • CRM engagement
  • GAPS

• Permit to Work Task

  Select Working at heights Confined space Hot work Trenching Excavation Lifting Rigging

  • Working at heights
  • Confined space
  • Hot work
  • Trenching Excavation
  • Lifting Rigging

• Simple description of work being done

• Is the permit available at the work location or on iauditor

  Yes

  No

• Stop job and follow reporting structure

  Yes

  No

• Are all parts of the permit filled out correctly

  Yes

  No

• Are employees trained and competent at their assigned roles ( Authorized users, Competent persons, spotters)

  Yes

  No

• What changes or actions need to be made

• Are all hazards identified and controlled

  Yes

  No

• Please list corrective actions

• Photo of work location or task

  Media

• Comments

• Task category

  Critical risk task

  High risk task

  Standard task

• Type of Observation

  Select Initial Follow Up Planned Observation Unplanned Observation

  • Initial
  • Follow Up
  • Planned Observation
  • Unplanned Observation

• Reason for Observation

  Select Critical Task New Worker Incident Follow up Good Performer Needs Coaching Other

  • Critical Task
  • New Worker
  • Incident Follow up
  • Good Performer
  • Needs Coaching
  • Other

• Task Description

• Is the worker trained for the task observed?

  Yes

  No

  N/A

• Job must be stopped until training is updated.

• Has a work place inspection been documented?

  Yes

  No

  N/A

• A document workplace exam must be conducted prior the job commencing

• Please select any improvement opportunities

  Select Training Tools Equipment Systems Other (please comment) None

  • Training
  • Tools
  • Equipment
  • Systems
  • Other (please comment)
  • None

• What training actions are required

• What tool improvements are required

• What equipment improvements are required

• What systems improvements are required

• Photos of work area

  Media

• Total Training Hours:

• Did the Trainee properly demonstrate a work place/pre-operational inspection?

  Yes

  No

• Did the Trainee properly demonstrate operation in a non-production setting?

  Yes

  No

• Did the Trainee properly demonstrate operation in a production setting?

  Yes

  No

• Has the Trainee demonstrated the ability to properly perform this job/task?

  Yes

  No

• Were there deficiencies in procedures or in performance of the task?

  Yes

  No

• What deficiencies

• Does the trainee need additional training?

  Yes

  No

• What follow up training is required

• Add photo of work area

  Media

• What were the general items discussed

  Health/Safety/Environmental

  New ideas

  Work/life concerns

  Other (please comment)

• What comments

• What new ideas

• What concerns

• Overall tone of conversation

  Positive

  Negative

  Neutral

• Any follow up needed

  Yes

  No

• Photo of work location

  Media

• Please name as many CRM's as you can

  Select Not able to name any Bulk Chemical- acid, cyanide, caustic Cable Handling- Shovel or Dewatering Fatigue Heavy equipment operation- cab to dove tail and parking areas Entanglement- Working around conveyor belts Lifting Rigging Towing- Lifting and rigging and/or Towing trailers/pipes Haul truck and small vehicle interactions-Intersections and one lane roads Working at heights- Removing components, deliveries and offloads Mid duty braking systems entering the pit Maintenance on Pressurized systems- Valves in plants Fueling equipment- fueling haul trucks at the fuel skid Ground control- Falling material from equipment working on a high wall Ground control- Equipment near a high wall Equipment fires- Hot work in a confined space Shovel swing radius- Bucket and counterweight Energy isolation- Live testing Working around underground voids Cutting tramp metal out of the crusher

  • Not able to name any
  • Bulk Chemical- acid, cyanide, caustic
  • Cable Handling- Shovel or Dewatering
  • Fatigue
  • Heavy equipment operation- cab to dove tail and parking areas
  • Entanglement- Working around conveyor belts
  • Lifting Rigging Towing- Lifting and rigging and/or Towing trailers/pipes
  • Haul truck and small vehicle interactions-Intersections and one lane roads
  • Working at heights- Removing components, deliveries and offloads
  • Mid duty braking systems entering the pit
  • Maintenance on Pressurized systems- Valves in plants
  • Fueling equipment- fueling haul trucks at the fuel skid
  • Ground control- Falling material from equipment working on a high wall
  • Ground control- Equipment near a high wall
  • Equipment fires-
  • Hot work in a confined space
  • Shovel swing radius- Bucket and counterweight
  • Energy isolation- Live testing
  • Working around underground voids
  • Cutting tramp metal out of the crusher

• What CRM's are you most exposed to

  Select Not able to name any Bulk Chemical- acid, cyanide, caustic Cable Handling- Shovel or Dewatering Fatigue Heavy equipment operation- cab to dove tail and parking areas Entanglement- Working around conveyor belts Lifting Rigging Towing- Lifting and rigging and/or Towing trailers/pipes Haul truck and small vehicle interactions-Intersections and one lane roads Working at heights- Removing components, deliveries and offloads Mid duty braking systems entering the pit Maintenance on Pressurized systems- Valves in plants Fueling equipment- fueling haul trucks at the fuel skid Ground control- Falling material from equipment working on a high wall Ground control- Equipment near a high wall Equipment fires- Hot work in a confined space Shovel swing radius- Bucket and counterweight Energy isolation- Live testing Working around underground voids Cutting tramp metal out of the crusher

  • Not able to name any
  • Bulk Chemical- acid, cyanide, caustic
  • Cable Handling- Shovel or Dewatering
  • Fatigue
  • Heavy equipment operation- cab to dove tail and parking areas
  • Entanglement- Working around conveyor belts
  • Lifting Rigging Towing- Lifting and rigging and/or Towing trailers/pipes
  • Haul truck and small vehicle interactions-Intersections and one lane roads
  • Working at heights- Removing components, deliveries and offloads
  • Mid duty braking systems entering the pit
  • Maintenance on Pressurized systems- Valves in plants
  • Fueling equipment- fueling haul trucks at the fuel skid
  • Ground control- Falling material from equipment working on a high wall
  • Ground control- Equipment near a high wall
  • Equipment fires-
  • Hot work in a confined space
  • Shovel swing radius- Bucket and counterweight
  • Energy isolation- Live testing
  • Working around underground voids
  • Cutting tramp metal out of the crusher

• How are you involved in the CRM program?

  Select Through the Bonus program I do verifications During workplace exams I work around Critical risks almost everyday I am a control owner Correcting hazards I am not involved in anyway Other (please comment)

  • Through the Bonus program
  • I do verifications
  • During workplace exams
  • I work around Critical risks almost everyday
  • I am a control owner
  • Correcting hazards
  • I am not involved in anyway
  • Other (please comment)

• How can you report a CRM hazard

  Supervisor

  Admin assistant

  Iauditor

  Paper report

  Don't know

• Is the employee able to explain how the CRM program affects the bonus program

  Yes

  No

• Add employees name so a follow up can be done

Goal

• What is the goal for today? (review with team)

Act

• What programs will be used to accomplish todays goal. (safe, efficient, production) (select all that apply)

  Select ACT card FLRA JHA Workplace exam Training/SOP's/SWP's Permits Supervisor follow up's (task obser/verifications) Other (add comment)

  • ACT card
  • FLRA
  • JHA
  • Workplace exam
  • Training/SOP's/SWP's
  • Permits
  • Supervisor follow up's (task obser/verifications)
  • Other (add comment)

• Add photo of selected programs

  Media

PLAN

• Are all tools, equipment and training correct for the job

  Yes

  No

• Stop work and get proper tools, equipment and training

• Was this plan reviewed by all affected team members

SCORE

• Overall, how well did we hit our goals today

  1

  2

  3

  4

  5

• What went well today (feed back from team)

• What can we improve on (feedback from team)