Generic EHS Audit Checklist for Proton Facility Ver. 1.0

• Name of audited location

• Conducted on

  Date

• Name and designation of auditor

• Address of audited location
  Address

• Auditee and their designation

• Equipment inspected

  ProBeam

  ProBeam360

• Name and designation of audit observers (e.g. customer employees, staff from regulatory authorities, etc.)

• Proton work activity assessment for audit purposes (e.g. servicing the couch, replacing parts on the gantry, etc.)

• Work activity documentation from iSiR or SAP system (e.g. PB-BAW-50007818)

• Audit document number for reference (e.g. 1-CIMC-Minokamo-Japan-31-Sep-2022). Ensure the PDF report file name is the same as the audit document number.

IMPORTANT REMINDER - Always ensure the health and safety of yourself and all other persons around you. When completing this checklist, please take action immediately to rectify any critical safety issues, rather than waiting to complete the report. Capture any details and escalate to your manager and the EHS team if required. All incidents and near misses should be reported immediately in the Healthineers EHS reporting tool myCority within 24hours.

1) Emergency Evacuation & Preparedness

• 1.1-Aisles, passageways, and exit doors are free from obstruction?

  Yes

  No

  N/A

• 1.1.1-Take photo(s) or video(s) of obstructed aisles, passageways, exit doors, etc.

  Media

• 1.2-Corridors/passageways are sufficiently wide for emergency evacuation?

  Yes

  No

  N/A

• 1.2.1-Take photo(s) or video(s) of narrow corridors/passageways.

  Media

• 1.3-First aid kit in a well-lit and accessible location?

  Yes

  No

  N/A

• 1.3.1-Record expiry date of first aid kits [Add note for additional first aid kits]

  Date

• 1.3.2-List of first aiders clearly marked at a visible location?

  Yes

  No

  N/A

• 1.3.2.1-Take photo of first aider list.

  Media

• 1.3.3-Is first aid kit inventory checked regularly?

  Yes

  No

  N/A

• 1.3.3.1-Take photo of first aid kit inventory check record.

  Media

• 1.3.4-First aid kit is well stocked?

  Yes

  No

  N/A

• 1.3.1-Take photo(s) or video(s) of first aid kit in dark or inaccessible location.

  Media

• 1.3.2-Record expiry date of first aid kits (yyyymmdd) [Add note for additional first aid kits]

  Date

• 1.3.3-List of first aiders clearly marked at a visible location?

  Yes

  No

  N/A

• 1.3.4-First aid kit inventory checked regularly?

  Yes

  No

  N/A

• 1.4.5-First aid kit is well stocked?

  Yes

  No

  N/A

• 1.4-Customer safety signs such as emergency evacuation map/emergency exits/hazard communication/emergency contacts are present and clearly visible to staff?

  Yes

  No

  N/A

• Comments/Notes/Findings not captured in checklist for Emergency Evacuation & Preparedness

2) General Workplace Safety and Health

• 2.1-Customer staff (supervisor, health physicist, doctor etc.) is present during inspection?

  Yes

  N/A

• 2.2-The workplace is not overcrowded or cramped?

  Yes

  No

  N/A

• 2.2.1-Take photo(s) or video(s) of overcrowded or cramped workplace.

  Media

• 2.3-Toilets/restrooms are clean, sufficient, well-ventilated with good lighting?

  Yes

  No

  N/A

• 2.3.1-Take photo(s) or video(s) of toilets/restrooms which are unclean/poorly ventilated/poorly illuminated.

  Media

• 2.4-The environmental conditions at the workplace is suitable and adequate with regards to temperature, light, humidity, noise, ventilation, dust, vibration, etc.

  Yes

  No

  N/A

• 2.4.1-Take photo(s) or video(s) of workplace with poor environmental conditions (e.g. dusty, humid, noisy, etc.).

  Media

• 2.5- Varian employees do not display prohibited practices (smoking, alcohol consumption, apply cosmetics, etc.)?

  Yes

  No

  N/A

• 2.6-The workplace displays good housekeeping practice to minimize slip, trip, fall, fire hazards?

  Yes

  No

  N/A

• 2.6.1-Take photo(s) or video(s) of workplace with poor housekeeping.

  Media

• 2.7-Are shelves/racks used at the workplace?

  Yes

  N/A

• 2.7.1-Shelves/racks display the safe working load (SWL)?

  Yes

  No

  N/A

• 2.7.1.1-Take photo of the SWL.

  Media

• 2.7.2-Shelves/racks are sturdy (not wobbly)?

  Yes

  No

  N/A

• 2.7.2.1-Take photo(s) or video(s) of wobbly shelves or racks.

  Media

• 2.7.3-Shelves/racks have good structural integrity (no sunken platform/rusting/missing parts, etc.)?

  Yes

  No

  N/A

• 2.7.3.1-Take photo(s) or video(s) of shelves/racks with poor structural integrity (rusty, sunken platform, parts missing, etc.)

  Media

• 2.8-Gas cylinders are safely secured to a fixed object and restrained?

  Yes

  No

  N/A

• 2.8.1-Gas detectors are installed?

  Yes

  No

  N/A

• 2.8.1-Take photo(s) of installed gas detector.

  Media

• 2.8.2-Gas detectors are up-to-date on calibration, servicing, and maintenance?

  Yes

  No

  N/A

• 2.8.3-Are the labels on the cylinders legible (can be read easily)?

  Yes

  No

  N/A

• 2.8.3.1-Take photo(s) or video(s) of defaced or unclear labels on the gas cylinder.

  Media

• 2.8.4-Unused cylinders have valve protection cap securely in place?

  Yes

  No

  N/A

• 2.8.4.1-Take photo(s) or video(s) of gas cylinders without valve protection cap in place.

  Media

• 2.8.5-Workers have access to the safety data sheets for the gas cylinders?

  Yes

  No

  N/A

• 2.8.5.1-Why do the workers do not have access to the safety data sheets?

• 2.8.6-Gas regulators show no signs of visible damage or deformity?

  Yes

  No

  N/A

• 2.8.6.1-Take photo(s) or video(s) of gas regulators.

  Media

• 2.9-Only compatible works are carried out? Example of incompatible work is working directly under another work activity that involves falling object hazards.

  Yes

  No

  N/A

• 2.10-Staff (record name in notes) can briefly describe what is incompatible work?

  Yes

  No

  N/A

• 2.11-Are non-Work-At-Height PPE (eyewear, ear plugs, masks, helmets, footwear, clothing, gloves, etc.) available for staff to use?

  Yes

  No

  N/A

• 2.12-List of PPE available?

  Select

• 2.13-Are auditees wearing the correct PPE during the audit?

  Yes

  No

  N/A

• Comments/Notes/Findings not captured in checklist for General Workplace Safety and Health

3) Electrical Safety

• 3.1-Electrical safety signs are visible at appropriate locations?

  Yes

  No

  N/A

• 3.1.1-Take photo(s) or video(s) of missing electrical safety signs.

  Media

• 3.2-Cables are not damaged (frayed/worn/exposed wiring/cut/etc.)?

  Yes

  No

  N/A

• 3.2.1-Take photo(s) or video(s) of damaged electrical cables.

  Media

• 3.3-Electrical connections (breakers/switches/plugs/etc.) are not damaged (burn marks/exposed wiring/holes/rust/etc.)?

  Yes

  No

  N/A

• 3.3.1-Take photo(s) or video(s) of damaged electrical connections.

  Media

• 3.4-Electrical connections are not likely to come in contact with water or other liquids?

  Yes

  No

  N/A

• 3.4.1-Take photo(s) or video(s) of electrical connections in close contact with water or liquids.

  Media

• 3.5-Cables and connections show no sign of unsafe modifications?

  Yes

  No

  N/A

• 3.5.1-Take photo(s) or video(s) of unsafe modifications on cables.

  Media

• 3.6-Extension cords are not daisy-chained (several extension cords connected together to increase accesibility to electrical power source)?

  Yes

  No

  N/A

• 3.6.1-Take photo(s) or video(s) of daisy-chained extension cords.

  Media

• 3.7-Plugs in use have safety logo?

  Yes

  No

  N/A

• 3.7.1-Take photo(s) or video(s) of plugs without safety logo.

  Media

• Comments/Notes/Findings not captured in checklist for Electrical Safety

4) Fire Safety

• 4.1-Fire extinguishers are inspected, not expired, in visibly good working condition and unobstructed?

  Yes

  No

  N/A

• 4.1.1-Take photo(s) or video(s) of uninspected/expired/damaged/obstructed fire extinguishers.

  Media

• 4.2-Fire hose reels are inspected, not expired, in visibly good working condition and unobstructed?

  Yes

  No

  N/A

• 4.2.1-Take photo(s) or video(s) of uninspected/expired/damaged/obstructed fire hose reels.

  Media

• 4.3-Fire detection system (smoke/heat/flame) is present?

  Yes

  No

  N/A

• 4.3.1-What is the fire detection system used?

• 4.3.2-Take photo(s) or video(s) of fire detection system.

  Media

• 4.3.3-Does the fire detection system show no visible signs of damage/corrosion?

  Yes

  No

  N/A

• 4.3.3.1-Take photo(s) or video(s) of damaged fire detection system.

  Media

• 4.3.1-Why the fire detection system is not present?

• 4.4-Fire suppression systems are present?

  Yes

  No

  N/A

• 4.4.1-What is the type of fire suppression system (e.g. water, chemical, gas, foam, etc.)?

• 4.4.2-Take photo(s) or video(s) of fire suppression system.

  Media

• 4.4.3-Does the fire suppression system show no visible signs of damage/corrosion?

  Yes

  No

  N/A

• 4.4.1-Why the fire suppression system is not present?

• 4.5-Electrical connections are not likely to come in contact with flammable materials?

  Yes

  No

  N/A

• 4.6-No stack/pile of combustible or flammable materials?

  Yes

  No

  N/A

• 4.6.1-Take photo(s) or video(s) of stack/pile of combustible or flammable materials.

  Media

• Comments/Notes/Findings not captured in checklist for Fire Safety

5) Chemical Safety

• Under the Globally Harmonized System of Classification and Labelling of Chemicals (effective 01 JAN 2017), it is the responsibility of the manufacturer/importer to determine if their product is a hazardous chemical and if so, to correctly classify their product. If you are unsure about the classification of a chemical, you should contact your chemical supplier or the manufacturer/importer for more information. There are nine hazard pictograms in the GHS which represent the physical, health and environmental hazards. These are named: Explosives, Flammables, Oxidisers, Gasses under pressure, Corrosives, Acute toxicity, Environmental hazard, Harmful/irritant to ozone layer and Severe health hazards.
  

  

• 5.1-Chemicals are properly labeled according to GHS guidelines?

  Yes

  No

  N/A

• 5.1.1-Take photo(s) or video(s) of chemicals not labelled according to GHS guidelines.

  Media

• 5.2-Chemicals (including waste) are properly stored prior to disposal?

  Yes

  No

  N/A

• 5.2.1-Take photo(s) or video(s) of improperly stored chemicals (including waste).

  Media

• 5.3-Chemical spill kit is available for use at the site?

  Yes

  No

  N/A

• 5.3.1-Take photo(s) or video(s) of available chemical spill kit.

  Media

• 5.4-Staff are able to briefly explain how to properly use the chemical spill kit?

  Yes

  No

  N/A

• Comments/Notes/Findings not captured in checklist for Chemical Safety

6) Work-at-Height (WAH) Safety

• 6.1-There are no open sides from which a person could fall from?

  Yes

  No

• 6.1.1-Take photo(s) or video(s) of open sides from which a person could fall from.

  Media

• 6.2-There are no openings on the floor from which a person could fall into?

  Yes

  No

  N/A

• 6.2.1-Take photo(s) or video(s) of openings on the floor from which a person could fall into.

  Media

• 6.3-Height of guard rails comply with local regulations?

  Yes

  No

  N/A

• 6.3.1-If the height of the guard rails are non-compliant, what are the additional risk controls adopted?

• 6.3.2-Take photo(s) or video(s) of non-compliant guard rail height.

  Media

• 6.4-Gap distance in the guard rail comply with local regulations?

  Yes

  No

  N/A

• 6.4.1-Take photo(s) or video(s) of non-compliant gap distance in the guard rail.

  Media

• 6.5-Is/are the field engineers(s) aware to inspect WAH PPE before each use?

  Yes

  No

  N/A

• 6.5.1-Could staff briefly describe how to inspect WAH PPE before use in a satisfactory manner?

  Yes

  No

  N/A

• 6.6-There are no fragile surfaces from which a person could fall from?

  Yes

  No

  N/A

• 6.6.1-Take photo(s) or video(s) of fragile surfaces from which a person could fall from.

  Media

• 6.7-Ladders show no visible damage/deformity?

  Yes

  No

  N/A

• 6.7.1-Take photo(s) or video(s) of damaged or deformed ladder.

  Media

• 6.8-Take photos of ladders with attached safety standard label

  Media

• 6.9-Are staff aware of the need to inspect the ladder before use?

  Yes

  No

  N/A

• 6.10-Scaffolds and their components are regularly inspected by a competent person according to local regulations?

  Yes

  No

  N/A

• 6.10.1-Take photo(s) or video(s) of scaffold inspection record.

  Media

• 6.11-Scaffolds show no sign of visible damage/deformity?

  Yes

  No

  N/A

• 6.11.1-Take photo(s) or video(s) of damaged or deformed scaffolds.

  Media

• 6.12-Are staff aware of the need to inspect the scaffold before use?

  Yes

  No

  N/A

• 6.13-Two horizontal and parallel guardrails on each side are in place and properly installed?

  Yes

  No

  N/A

• 6.13.1-Take photo(s) or video(s) of scaffold showing missing guardrail.

  Media

• 6.14-The scaffolds platforms have toe-boards on all sides?

  Yes

  No

  N/A

• 6.15-Does the scaffold come with a user manual supplied by the manufacturer?

  Yes

  No

  N/A

• 6.16-Was the scaffold built to a recognized safety standard?

  Yes

  No

  N/A

• 6.17-Sample several WAH PPE. Do these show no visible signs of damage/deformity?

  Yes

  No

  N/A

• 6.17.1-Take photo(s) or video(s) of damaged or deformed WAH PPE.

  Media

• 6.18-Sample several WAH PPE. Are these current and not past expiry date?

  Yes

  No

  N/A

• 6.18.1-Take photo(s) or video(s) of expired WAH PPE.

  Media

• 6.19-Are the WAH PPE properly stored and easily accessible?

  Yes

  No

  N/A

• 6.19.1-Take photo(s) or video(s) of improperly stored or inaccessible WAH PPE.

  Media

• Comments/Notes/Findings not captured in checklist for WAH Safety

7) Lifting Equipment Safety (e.g. crane/hoist/pulleys/rope/etc.)

• 7.1-Lifting tools/equipment show no signs of visible damage/deformity?

  Yes

  No

  N/A

• 7.1.1-Take photo(s) or video(s) of damaged or deformed lifting tools/equipment.

  Media

• 7.2-Lifting tools/equipment are regularly inspected by a competent person according to local regulations?

  Yes

  No

  N/A

• 7.3-Are staff aware of the need to inspect the lifting equipment/tool before use?

  Yes

  No

  N/A

• Comments/Notes/Findings not captured in checklist for Lifting Equipment Safety

8) Lockout and Tagout (LOTO)

• 8.1-Lockout devices have no visible damage/deformity?

  Yes

  No

  N/A

• 8.1.1-Take photo(s) or video(s) of damaged or deformed lockout devices.

  Media

• 8.2-Tags are legible, robust, and and understandable by all staff who may be in the area?

  Yes

  No

  N/A

• 8.2.1-Take photo(s) or video(s) of unreadable or damaged tags.

  Media

• Comments/Notes/Findings not captured in checklist for LOTO Safety

9) Inspection on Other Equipment and Hand Tools

• 9.1-Sample several hand tools. Tools show no visible signs of damage/deformity?

  Yes

  No

  N/A

• 9.1.1-Take photo(s) or video(s) of damaged or deformed hand tools.

  Media

• 9.2-Where applicable, safety labels/signs are clear and affixed to the equipment?

  Yes

  No

  N/A

• 9.3-Patient treatment room/couch is clean and free from any observable potential biological hazards?

  Yes

  No

  N/A

• 9.3.1-Take photo(s) or video(s) of couch with observable potential biological hazards.

  Media

• 9.4-Hand tools are stored safely in an organized manner?

  Yes

  No

  N/A

• 9.4.1-Take photo(s) or video(s) of properly stored hand tools.

  Media

• Comments/Notes/Findings not captured in checklist for Equipment and Hand Tools Inspection

10) Waste Management (excludes chemical, radioactive waste)

• 10.1-Is there an agreement with the Customer for waste management (parts for scrapping, e-waste, etc.)?

  Yes

  N/A

• 10.2-Is the waste properly segregated and stored prior to disposal?

  Yes

  No

  N/A

• 10.2.1-Take photo(s) or video(s) of improperly stored or segregated waste.

  Media

• Comments/Notes/Findings not captured in checklist for Waste Management

1) Emergency Evacuation & Preparedness

• 1.1-Has Varian staff received EHS instruction/training/communication from customer?

  Yes

  No

  N/A

• 1.1.1-Take photo(s) or video(s) of document/record showing EHS instruction/training/communication.

  Media

• 1.2-First aider keeps a record of treatments?

  Yes

  No

  N/A

• Comments/Notes/Findings not captured above for Emergency Evacuation & Preparedness

2) General Workplace Safety and Health

• 2.1-Staff has access to updated EHS documents (procedures/risk assessments, etc.) from Varian Corporate EHS?

  Yes

  No

  N/A

• 2.2-Staff has access to the latest work procedures either on the iSiR, SAP, or GCS platform?

  Yes

  No

  N/A

• 2.3-How many courses in the VPS training matrix have been completed? Do also state the total number of courses in the matrix.

• 2.4-Is there an appointed safety officer/lead to oversee daily EHS activities at the workplace?

  Yes

  No

  N/A

• 2.4.1-Provide the name and designation of the appointed safety officer/lead.

• 2.5-Do staff perform work using electric or gas welding machines?

  Yes

  N/A

• 2.5.1-Please provide evidence of relevant training.

• 2.6-Do staff operate forklifts?

  Yes

  N/A

• 2.6.1-Please provide evidence of relevant training.

• 2.7-Where required by local regulations and excluding radiation safety, has staff completed medical examinations as a requirement to perform work?

  Yes

  No

  N/A

• 2.7.1-Please provide evidence of medical examinations (e.g. tax invoice, confirmation notice from medical examiner, etc.).

• 2.8-Site employees know to report incidents, near misses, and good observations to EHS and to the Site Manager?

  Yes

  No

  N/A

• 2.9-The site performs the monthly safety audit/inspections?

  Yes

  No

  N/A

• 2.9.1-Take photo(s) or video(s) of completed monthly safety audits or inspections records.

  Media

• 2.9.2-Document evidence that a process is in place to correct discrepancies found in the monthly safety audit/inspections.

  Yes

  No

  N/A

• Comments/Notes/Findings not captured above for General Workplace Safety and Health

3) Electrical Safety

• 3.1-Staff have completed Electrical Safety training courses on Learn4U? Examples of such training are VPS Electrical Safety Part 1 and Part 2 and VPS Electrical Safety Checklist.

  Yes

  No

  N/A

• 3.1.1-Please provide training records.

  Media

• 3.2-Provide evidence of other electrical safety training, if applicable.

  Media

• Comments/Notes/Findings not captured above for Electrical Safety.

4) Fire Safety

• 4.1-Provide evidence of fire safety training, if applicable.

  Media

• 4.2-Is there a list of appointed fire wardens?

  Yes

  No

  N/A

• 4.2.1-Take photo(s) or video(s) of fire warden list.

  Media

• 4.3-Provide evidence of fire warden training.

  Media

• Comments/Notes/Findings not captured above for Fire Safety

5) Chemical Safety

• 5.1-Workers have access to Safety data sheets (SDS), either in paper or softcopy?

  Yes

  No

  N/A

• 5.1.1-Take photo(s) or video(s) showing how workers access Safety Data Sheets.

  Media

• 5.2-Provide evidence of chemical safety training, if applicable.

  Media

• 5.3-Inventory of hazardous chemicals maintained and accessible on-site?

  Yes

  No

  N/A

• 5.3.1-Take photo(s) or video(s) of hazardous chemical inventory.

  Media

• Comments/Notes/Findings not captured above for Chemical Safety.

6) Work-at-Height (WAH) Safety

• 6.1-Staff performing WAH activities have the required license/training?

  Yes

  No

  N/A

• 6.1.1-Take photo(s) or video(s) showing records of WAH licenses/trainings.

  Media

• 6.2-Staff managing WAH activities have the required license/training?

  Yes

  No

  N/A

• 6.2.1-Take photo(s) or video(s) showing records of WAH licenses/trainings.

  Media

• 6.3-Is a list of WAH PPE assigned to staff available?

  Yes

  No

  N/A

• 6.3.1-Take photo(s) or video(s) of WAH PPE assignment list.

  Media

• 6.4-WAH PPE are under a regular maintenance/inspection program?

  Yes

  No

  N/A

• 6.4.1-Take photo(s) or video(s) of showing records of regular maintenance/inspection program.

  Media

• 6.5-Are there safe means of entry and exit for WAH work activities?

  Yes

  No

  N/A

• 6.5.1-Take photo(s) or video(s) of unsafe means of entry and exit for WAH activities.

  Media

• 6.6-Varian staff using ladders at work have completed Ladder Safety training on Learn4U? Examples of such training are EHS Safe Ladder Operation.

  Yes

  No

  N/A

• 6.6.1-Take photo(s) or video(s) of records showing ladder safety training.

  Media

• 6.7-Staff who move, operate, and inspect the scaffold are trained to recognize the hazards associated with it?

  Yes

  No

  N/A

• 6.7.1-Take photo(s) or video(s) of records showing scaffold operation and inspection training.

  Media

• 6.8-Staff have completed the EHS Fall Protection training on Learn4U?

  Yes

  No

  N/A

• Comments/Notes/Findings not captured above for Work-at-Height Safety.

7) Lifting Equipment Safety (e.g. crane/hoist/pulleys/rope/etc.)

• 7.1-Is there a list of lifting tools/equipment used by staff?

  Yes

  No

  N/A

• 7.2-Staff have completed training on operating overhead cranes?

  Yes

  N/A

• 7.3-Lifting equipment/tools have valid Lifting Machine (LM) certificate or equivalent document?

  Yes

  No

  N/A

• 7.3.1-Take photo(s) or video(s) of certificate or equivalent document.

  Media

• 7.4-Is there an established and implemented Lifting Plan?

  Yes

  No

  N/A

• 7.4.1-Take photo(s) or video(s) of Lifting Plan.

  Media

• Comments/Notes/Findings not captured above for Lifting Equipment Safety.

8) Lockout and Tagout (LOTO)

• 8.1-Staff have completed EHS Electrical Safety and Lockout/Tagout (LOTO) training on Learn4U?

  Yes

  No

  N/A

• 8.1.1-Please provide training records.

  Media

• 8.2-Staff could briefly describe the LOTO procedures in a satisfactory manner?

  Yes

  No

  N/A

• Comments/Notes/Findings not captured above for Lockout and Tagout (LOTO)

9) Lone Worker

• 9.1-Has the Site Manager identified the areas and tasks at the site where the Lone Worker Rule applies?

  Yes

  No

  N/A

• 9.2-Were the site employees trained on the Lone Worker Rule before work began?

  Yes

  No

  N/A

1) Work-at-Height (WAH) Safety

• 1.1-Name of interviewee and designation

• 1.2-Date of interview

  Date

• 1.3-Start time of interview

  Date

• 1.4-Staff could briefly describe the procedures to follow when working at the top of the gantry with the crane or lifeline as the anchor point?

  Yes

  No

  N/A

• 1.5-Staff could briefly describe the emergency procedures for WAH activities?

  Yes

  No

  N/A

• 1.6-End time of interview

  Date

• Comments/Notes/Findings not captured above for Work-at-Height (WAH) Safety

2) Electrical Safety

• 2.1-Name of interviewee and designation

• 2.2-Date of interview

  Date

• 2.3-Start time of interview

  Date

• 2.4-Staff could briefly describe the observer rule for work on exposed energized circuits of 50 V or greater?

  Yes

  No

  N/A

• Comments/Notes/Findings not captured above for Electrical Safety

3) Lockout and Tagout (LOTO)

• 3.1-Name of interviewee and designation

• 3.2-Date of interview

  Date

• 3.3-Start time of interview

  Date

• 3.4-Staff could briefly describe how to communicate during LOTO work when out of line of sight?

  Yes

  No

  N/A

• Comments/Notes/Findings not captured above for Lockout and Tagout (LOTO)

4) Work-at-Height (WAH) Safety Harness Demonstration

• 4.1-Name of interviewee and designation

• 4.2-Date of interview

  Date

• 4.3-Start time of interview

  Date

• 4.4-Staff could demonstrate putting on a safety harness correctly and adjusting to ensure good fit?

  Yes

  No

  N/A

• Comments/Notes/Findings not captures above for WAH Safety Harness Demonstration

• 1.1-Name of staff to be assessed, and his/her designation

• 1.2-Date of assessment

  Date

• 1.3-Start time of assessment

  Date

1.4-Choose one of the following work activities for assessment.

• 1.4.1-Observe in real-time how the EHS monthly inspection is done by the site team using the provided checklist.

  Yes

  N/A

• 1.4.2-Mock demonstration of emergency rescue of fallen colleague hanging from a harness.

  Yes

  N/A

• 1.4.3-For specific work activity based on Varian maintenance and service documents, click Yes, and provide details in Question 1.5.

  Yes

  N/A

• 1.5-Description of work activity

• 1.5.1-Observed uncontrolled risks?

  Select General Safety and Health Electrical Fire Work-at-Height (WAH) Chemical Lockout-Tagout (LOTO) Radiation Lifting Equipment None observed

  • General Safety and Health
  • Electrical
  • Fire
  • Work-at-Height (WAH)
  • Chemical
  • Lockout-Tagout (LOTO)
  • Radiation
  • Lifting Equipment
  • None observed

• 1.5.2-What are the uncontrolled risks?

• Comments/Notes/Findings not captured above for Work Activity Assessment

• 1.1-Summary of audit findings

• 1.2-Summary of audit actions

• 1.3-Conclusion

• 1.1-Auditor name and signature

  Sign

• 1.2-Auditee name and signature

  Sign

• 1.3-Auditee name and signature (sign as N.A if not applicable)

  Sign

• 1.4-Auditee name and signature (sign as N.A if not applicable)

  Sign

• 1.5-Auditee name and signature (sign as N.A if not applicable)

  Sign

• 1.6-Auditee name and signature (sign as N.A if not applicable)

  Sign

• 1.7-Auditee name and signature (sign as N.A if not applicable)

  Sign

• 1.8-Audit observers (sign as N.A if not applicable)

  Sign

• 1.9-Audit end date

  Date

• 1.10 Audit end time

  Date