Information

  • Audit Title

  • Last Name, First Name

  • Conducted on

  • Prepared by

  • Location

  • Personnel

  • Business Unit

  • Function/Entity

  • Workgroup

  • Job Title

Accountability

  • 1a. When was the last time you were coached or encouraged from a member of management on safety, that was not at a regularly scheduled safety meeting?

  • 1b. Can you describe the situation and was the coaching effective?

Safety Commitment

  • 2a. On a scale of 1-10, with 10 being the best, how committed are you to safety?

  • Select from range

  • 2b. On a scale of 1-10, with 10 being the best, how committed is your leadership to safety?

  • Select from range

Human Performance

  • 3a. On a scale of 1-10, with 10 being the best, how effective do you consider Human Performance to be?

  • Select from range

  • 3a. On a scale of 1-10, with 10 being for each task, 5 being sometimes, and 1 being never, how often do you use Human Performance?

  • Select from range

Conservative Decision Making

  • 4a. Prior to making a decision, do you think Likelihood or Consequences?

  • 4b. What factors do you consider when making a decision?

Close Calls / Good Catch Reporting

  • 5a. When is the last time you reported a Close Call / Good Catch? What was the CC/GC pertaining to?

Vehicle Inspection

  • 1. Are weekly vehicle inspections (for vehicles GVW >10,000 lbs) properly documented and present in the vehicle?

  • 17B.2

  • 2. Was the vehicle properly parked before the inspection?

  • Was the vehicle backed in, or parked where the vehicle could pull through? 17A.13
    If backing in was not applicable then N/A.

  • 3. Are tires in visibly good condition and look to be properly inflated?

  • 4. Are the wipers in good working condition?

  • 5. Are there any obstructions keeping the driver from seeing out of the windows or mirrors?

  • 6. Does the horn work?

  • 7. Is the driver using three points of contact for entering or exiting the vehicle?

  • 17A7

  • 8. Does the vehicle have a fire extinguisher?

  • 17A.18

  • 9. Are all inspection stickers and licenses visible and within date?

  • 17A2

Smith System Driving Keys

  • 10. Did the driver demonstrate the 5 Smith Driving Keys?

  • 11. Aim High in Steering?

  • 12. Get the Big Picture?

  • 13. Keep Your Eyes Moving?

  • 14. Leave Yourself an Out?

  • 15. Make Sure They See You?

General Driving Questions

  • 16. Did the driver yield appropriately in traffic, yield to pedestrians as well as slowing at all railroad crossings?

  • 17A12

  • 17. Did the driver scan their mirrors?

  • 18. Are the mirrors properly aligned?

  • Ask the driver if he can see out of all the mirrors.

  • 19. Did the driver follow vehicles at a safe and appropriate distance?

  • 20. Did the driver maintain enough space in front of them while stopped at a red light or stop sign?

  • approximate length of vehicle.

  • 21. Did the properly park their vehicle, if a stop was made during the inspection?

  • With the flow of traffic, cone, flashers, and beacons as needed. 17A17, 17A2

  • 22. Were seat belts in place before departure and constantly in use?

  • 1H.4

  • 23. Did the driver utilize a hands free device for communication?

  • 1J.1-1J.5 outlines the use of cell phones and hands free devices while operating a motor vehicle.

  • 24. Did the driver keep their vehicle in the center of the lane?

  • 1H.1 & 1H.3

  • 25. Were the drivers lane changes minimized?

  • 1H.1 & 1H.3

  • 26. Did the driver remain focused while driving?

  • 1H.1 & 1H.3 No eating, shuffling through paper work, etc.

  • 27. Did the driver use turn signals properly?

  • 1H.1 & 1H.3

  • 28. Did the driver travel at or below the posted speed limit?

  • 17A.1-17A.3 Speed should be adjusted for weather conditions.

  • 29. Did the driver avoid backing whenever possible?

  • 17A.13

  • 30. If the drivers view was obstructed, was a spotter used to back the vehicle into a parking spot?

  • 17A.14

  • 31. Did the driver close their laptop before departure.

  • 1J.5

  • 32. Did the driver use flashers or beacons when impeding the flow of traffic?

  • Should be used while patrolling lines or looking for an address.

  • Comments

  • Signiture

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.