Information

  • Audit Title

  • Format: Last name, first name

  • Location

  • Conducted on

  • Prepared by

  • Personnel

  • Business Unit

  • Function/Entity

  • Workgroup

  • Job Title

Accountability

  • 1a. When was the last time you were coached from a member of management on safety?

  • 1b. Can you describe the situation and did you consider it to be an effective coaching moment?

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

  • 3b. On a scale of 1-10, with 10 being very often, 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?

Vehicle Inspection

  • 1. Did they perform their Circle of Safety?<br> <br>

  • 2. Are all lights functioning?

  • 3. Are tires in good condition and all valve stem covers in place?

  • 4. Are the wipers in good working condition?

  • 5. Is the windshield free of cracks or chips that would potentially obstruct the driver's field of vision?

  • 6. Are all loads in the truck bed secure?

  • 7. Does the driver have an unobstructed view out of the windows and mirrors?

  • 8. Is the employee using 3 points of contact when entering or exiting the vehicle?

  • 9. Did the vehicle pass inspection today?

  • 10. Has the DOT pre-trip checklist and all associated forms for DOT vehicles and trailers been completed?

Smith Driving Keys

  • 11. Did the employee use the five Smith Driving Keys?

  • 12. Aim High In Steering

  • 13. Get the Big Picture

  • 14. Keep Your Eyes Moving

  • 15. Leave Yourself An Out

  • 16. Make Sure They See You

General Driving Questions

  • 17. Did they yield appropriately in traffic as well as yield to pedestrians?

  • 18. Did they scan their mirrors?

  • 19. Are the mirrors properly aligned?

  • 20. Did they follow vehicles at a safe and appropriate distance?

  • 21. Did they leave enough space (length of a vehicle) in front of them when stopping at a red light?

  • 22. Did they properly park the vehicle (with the flow of traffic, cones as needed, etc)?

  • 23. Were seat belts in place before leaving and constantly used?

  • 24. Did they utilize a hands-free device for communication?

  • 25. Did they maintain their vehicle in the center of the lane?

  • 26. Were their lane changes minimized?

  • 27. While turning, did they maintain their proper lane?

  • 28. Did they remain focused while driving (not eating, doing paperwork, etc)?

  • 29. Did they use proper turn signals?

  • 30. Were headlights always on?

  • 31. Did they use flashers when appropriate?

  • 32. Did they travel at or below posted speed limits (per weather, driving conditions)?

  • 33. Did they avoid known areas of construction to avoid traffic congestion/use alternate route?

  • 34. Did they avoid backing up whenever possible?

  • 35. If the driver's view was obstructed, was a spotter used to back up the vehicle?

  • 36. Did they remove the key when parked?

  • 37. Did they complete the DOT post-trip checklist and any forms associated with DOT vehicles and trailers?

  • Comments

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.