GSS - SAFETY EVALUATION FORM

• Client Evaluation Completed for

• Name of client and site Audit completed for

• AMPOL Task number

• Type of work being completed

  PM Routine Maintenance

  Reactive - rectification works

Guardian Safety Solutions

• Evaluation completed by:

• Evaluation on Employee Name:

• Date of evaluation:

  Date

Site of Evaluation:

• 1.1 Check Employee has relevant license

  Yes

  No

• 1.2 Check Employee has relevant permits 2

  Yes

  No

• 2.1 Check Employee complies with site attendance - site sign in book

  Yes

  No

• 5.1 Check employee utilized all PPE specific for the site

  Select PPE - Clothing Long Shirt/long pants PPE - Hi Vis Vest/shirt PPE - Safety Boots

  • PPE - Clothing Long Shirt/long pants
  • PPE - Hi Vis Vest/shirt
  • PPE - Safety Boots

• 5.2 Check employee sets work area as required for the specific site (attach photo)

  Yes

  No

• 5.3 Check employee complies with all site specific requirements

  Select WPCG Completed SWMS completed

  • WPCG Completed
  • SWMS completed

• 5.4 Check employee complies with Guardian Requirements

  Select FireMate - Safety Checklist Completed FireMate - Photos of defects recorded

  • FireMate - Safety Checklist Completed
  • FireMate - Photos of defects recorded

PERSON PROTECTIVE EQUIPMENT| PRECAUTIONS

• OVERALL EVALUATION AND COMMENTS

• Employee Signature

  Sign

• Evaluators Signature

  Sign