Gemba draft

• Site (STV, ADD or HAR)
  Address

• Location of Works

• Date

  Date

• Time

  Date

• Prepared by

• Is the observed work under a Permit to work

  Yes

  No

• Project number / Work order number

• Resposible person

• Permit Issuer

• Permit Number

• Contractor involved

General Background

• Are the PTW and RAMS easily located?

  Yes

  No

• Are site access and egress routes clear?

  Yes

  No

• Is the site tidy?

  Yes

  No

• Is the site PPE requirement clearly identified?

  Yes

  No

• Are First Aid Supplies immediately available?

  Yes

  No
Observation

• Observation

• Compliant

  Non-Compliant

  N/A