Title Page

  • Conducted on

  • Prepared by

  • Office Location
  • FSM

  • The Health & Safety Manager evaluates every FSM at least once each year. Prior to the FSM's evaluation, the Health& Safety Manager visits at least 20% of the technicians on the FSM's team to compare results with the FSM's evaluation of that technician. After the FSM evaluation, the Health & Safety Manager sets a meeting with the FSM to review the results and scores and sends a copy of the results of that meeting to the Regional Operations Manager and the Director of Field Operations.

  • Was every technician who was employed at the start of the quarter on the FSM's team evaluated during the quarter?

  • What was their team's speeding percentage compared to the last evaluation?

  • What was their team's Harsh Brake compared to the last evaluation?

  • What is their team's "Backing When Leaving" compared to the last evaluation?

  • What was their team's auto loss rate compared to their last evaluation?

  • What was their Injury Loss Rate compared to the last evaluation?

  • Were the safety metrics stated in the PREPARATION section of the Technician's Safety Evaluations provided by the FSM accurate?

  • Were the Health & Safety Manager's evaluation of an audited technician a similar experience? (if not then a joint evaluation of another selected technician will be scheduled for coaching purposes)

  • Were all pictures that were required provided?

  • Were all exceptions found by the FSM on evaluations followed up on and corrected in an appropriate time frame?

  • Was the average time for this FSM to respond to an alert from their team?

  • Are there references on the TPS reports that the new hire was supported by the FSM?

  • Does the FSM's van and the Office have a backup of safety equipment to be used for immediate replacement (hardhat, safety glasses, first aid supplies, fire extinguishers, headlamps)?

  • Did the FSM provide a complete and timely (within 24hrs) a Root Cause Analysis for every injury that happened to their team during the quarter?

  • Was the suggested action on the Root Cause Analysis appropriate to eliminate/reduce similar incidents? Was it followed up on?

  • FSM Signature

  • Health & Safety Manager Signature

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