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?

Emergency Response Plan

  • 1. Do you know where the Safe Room is located in this facility? If yes, name/describe the location.<br> <br>

  • 2. Do you know where the assembly point outside this facility is for an emergency evacuation? If yes, name/describe the location.

  • 3. Do you know who is responsible for checking your name off of the employee roster once you arrive at the assembly point? If yes, name that person(s).

  • 4. Do you know how you are notified to find shelter in place for a weather event? If yes, describe the alarm.

  • 5. Do you know what the alarm/notification is in event of fire or other emergency evacuation? If yes, describe alarm.

  • 6. Do you know the escape route to get to the assembly point outside the facility? If yes, provide details on primary route and alternate route.

  • Depending on the situation, have the employee either walk you along the route or describe the route. The goal is to determine if there are obstructions in the pathway; if the employee describes the route, walk it after the inspection to check for obstructions. NOTE: obstructions are not necessarily the fault of the employee, and should be included merely as a note for future reference.

Workplace Hazards

  • 7. Do you know who is trained in CPR and first aid on site? If yes, provide at least 2 names if applicable.

  • 8. Do you know what information is contained on a Safety Data Sheet (SDS)? If yes, provide example and where the sheets are located at your facility.

  • 9. Can you describe a situation where you would need the information from the SDS book?

  • 10. Do you know who in this facility you could ask a safety question and/or who could assist with a safety issue? If yes, provide name.

  • 11. Do you have a bulletin board or OSHA poster on site that provides safety information? If yes, what information does it contain?

Safety Participation

  • 12. How often do you attend safety meetings? What were some recent topics from the safety meetings?

  • 13. Can you give me an example of how you would encourage your fellow workers to choose safe office practices?

  • 14. Can you give me an example of how you have used topics from the safety meetings in your home or personal life?

  • Comments

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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.