Information

  • Audit Title

  • Site

  • Conducted on

  • Prepared by

Participant Information

Participant Information 1

  • Enter the person's name

  • Is the person a contractor?

  • Enter contracting company name

  • What SEG does the person work in?

Participant Information 2

  • Enter the person's name

  • Is the person a contractor?

  • Enter contracting company name

  • What SEG does the person work in?

Participant Information 3

  • Enter the person's name

  • Is the person a contractor?

  • Enter contracting company name

  • What SEG does the person work in?

Participant Information 4

  • Enter the person's name

  • Is the person a contractor?

  • Enter contracting company name

  • What SEG does the person work in?

Participant Information 5

  • Enter the person's name

  • Is the person a contractor?

  • Enter contracting company name

  • What SEG does the person work in?

Participant Information 6

  • Enter the person's name

  • Is the person a contractor?

  • Enter contracting company name

  • What SEG does the person work in?

Participant Information 7

  • Enter the person's name

  • Is the person a contractor?

  • Enter contracting company name

  • What SEG does the person work in?

Participant Information 8

  • Enter the person's name

  • Is the person a contractor?

  • Enter contracting company name

  • What SEG does the person work in?

Participant Information 9

  • Enter the person's name

  • Is the person a contractor?

  • Enter contracting company name

  • What SEG does the person work in?

Participant Information 10

  • Enter the person's name

  • Is the person a contractor?

  • Enter contracting company name

  • What SEG does the person work in?

Participant Information 11

  • Enter the person's name

  • Is the person a contractor?

  • Enter contracting company name

  • What SEG does the person work in?

Participant Information 12

  • Enter the person's name

  • Is the person a contractor?

  • Enter contracting company name

  • What SEG does the person work in?

Participant Information 13

  • Enter the person's name

  • Is the person a contractor?

  • Enter contracting company name

  • What SEG does the person work in?

Participant Information 14

  • Enter the person's name

  • Is the person a contractor?

  • Enter contracting company name

  • What SEG does the person work in?

Participant Information 15

  • Enter the person's name

  • Is the person a contractor?

  • Enter contracting company name

  • What SEG does the person work in?

Participant Information 16

  • Enter the person's name

  • Is the person a contractor?

  • Enter contracting company name

  • What SEG does the person work in?

Participant Information 17

  • Enter the person's name

  • Is the person a contractor?

  • Enter contracting company name

  • What SEG does the person work in?

Participant Information 18

  • Enter the person's name

  • Is the person a contractor?

  • Enter contracting company name

  • What SEG does the person work in?

Participant Information 19

  • Enter the person's name

  • Is the person a contractor?

  • Enter contracting company name

  • What SEG does the person work in?

Participant Information 20

  • Enter the person's name

  • Is the person a contractor?

  • Enter contracting company name

  • What SEG does the person work in?

Airborne Dust & Fume

  • Airborne Dust and Fume questions apply to the following high risk SEGs only:
    - Shotfirer
    - Driller
    - Daracon Crusher Operator
    - Boilermaker
    - Tyre Fitter

  • Only Employees and Cat 1 Contractors will have fit testing information with the Occ Health Nurse

Dust - Shotfirer

  • Have airborne hazards been identified in the Take5/JHA and have controls been implemented to reduce exposure to dust or welding fume?

  • Controls may include:
    Windows up, roads/drill or shot pattern watered, dust suppression sprays in use, adequate distance from dust generating equipment (eg loading unit), use of wet cleaning methods or vacuum, clean surfaces, local exhaust ventilation or fans in use during welding, use of respirators, cabin door and window seals intact, cabin pressurisation.

  • Has the participant been scheduled for a fit test and have they attended and passed?

  • See the site Occ Health Nurse for attendance records.
    The fit test must be conducted for the respirator that the individual uses.

Dust - Shotfirer

  • Have airborne hazards been identified in the Take5/JHA and have controls been implemented to reduce exposure to dust or welding fume?

  • Controls may include:
    Windows up, roads/drill or shot pattern watered, dust suppression sprays in use, adequate distance from dust generating equipment (eg loading unit), use of wet cleaning methods or vacuum, clean surfaces, local exhaust ventilation or fans in use during welding, use of respirators, cabin door and window seals intact, cabin pressurisation.

  • Has the participant been scheduled for a fit test and have they attended and passed?

  • See the site Occ Health Nurse for attendance records.
    The fit test must be conducted for the respirator that the individual uses.

Dust - Driller

  • Have airborne hazards been identified in the Take5/JHA and have controls been implemented to reduce exposure to dust or welding fume?

  • Controls may include:
    Windows up, roads/drill or shot pattern watered, dust suppression sprays in use, adequate distance from dust generating equipment (eg loading unit), use of wet cleaning methods or vacuum, clean surfaces, local exhaust ventilation or fans in use during welding, use of respirators, cabin door and window seals intact, cabin pressurisation.

  • Has the participant been scheduled for a fit test and have they attended and passed?

  • See the site Occ Health Nurse for attendance records.
    The fit test must be conducted for the respirator that the individual uses.

  • Is the person in adherence with the facial hair policy for site?

Dust - Driller

  • Have airborne hazards been identified in the Take5/JHA and have controls been implemented to reduce exposure to dust or welding fume?

  • Controls may include:
    Windows up, roads/drill or shot pattern watered, dust suppression sprays in use, adequate distance from dust generating equipment (eg loading unit), use of wet cleaning methods or vacuum, clean surfaces, local exhaust ventilation or fans in use during welding, use of respirators, cabin door and window seals intact, cabin pressurisation.

  • Has the participant been scheduled for a fit test and have they attended and passed?

  • See the site Occ Health Nurse for attendance records.
    The fit test must be conducted for the respirator that the individual uses.

  • Is the person in adherence with the facial hair policy for site?

Dust - Daracon Crusher Operator

  • Have airborne hazards been identified in the Take5/JHA and have controls been implemented to reduce exposure to dust or welding fume?

  • Controls may include:
    Windows up, roads/drill or shot pattern watered, dust suppression sprays in use, adequate distance from dust generating equipment (eg loading unit), use of wet cleaning methods or vacuum, clean surfaces, local exhaust ventilation or fans in use during welding, use of respirators, cabin door and window seals intact, cabin pressurisation.

  • Has the participant been scheduled for a fit test and have they attended and passed?

  • See the site Occ Health Nurse for attendance records.
    The fit test must be conducted for the respirator that the individual uses.

  • Is the person in adherence with the facial hair policy for site?

Dust - Daracon Crusher Operator

  • Have airborne hazards been identified in the Take5/JHA and have controls been implemented to reduce exposure to dust or welding fume?

  • Controls may include:
    Windows up, roads/drill or shot pattern watered, dust suppression sprays in use, adequate distance from dust generating equipment (eg loading unit), use of wet cleaning methods or vacuum, clean surfaces, local exhaust ventilation or fans in use during welding, use of respirators, cabin door and window seals intact, cabin pressurisation.

  • Has the participant been scheduled for a fit test and have they attended and passed?

  • See the site Occ Health Nurse for attendance records.
    The fit test must be conducted for the respirator that the individual uses.

  • Is the person in adherence with the facial hair policy for site?

Dust - Boilermaker

  • Have airborne hazards been identified in the Take5/JHA and have controls been implemented to reduce exposure to dust or welding fume?

  • Controls may include:
    Windows up, roads/drill or shot pattern watered, dust suppression sprays in use, adequate distance from dust generating equipment (eg loading unit), use of wet cleaning methods or vacuum, clean surfaces, local exhaust ventilation or fans in use during welding, use of respirators, cabin door and window seals intact, cabin pressurisation.

  • Has the participant been scheduled for a fit test and have they attended and passed?

  • See the site Occ Health Nurse for attendance records.
    The fit test must be conducted for the respirator that the individual uses.

  • Is the person in adherence with the facial hair policy for site?

Dust - Boilermaker

  • Have airborne hazards been identified in the Take5/JHA and have controls been implemented to reduce exposure to dust or welding fume?

  • Controls may include:
    Windows up, roads/drill or shot pattern watered, dust suppression sprays in use, adequate distance from dust generating equipment (eg loading unit), use of wet cleaning methods or vacuum, clean surfaces, local exhaust ventilation or fans in use during welding, use of respirators, cabin door and window seals intact, cabin pressurisation.

  • Has the participant been scheduled for a fit test and have they attended and passed?

  • See the site Occ Health Nurse for attendance records.
    The fit test must be conducted for the respirator that the individual uses.

  • Is the person in adherence with the facial hair policy for site?

Dust - Tyre Fitter

  • Have airborne hazards been identified in the Take5/JHA and have controls been implemented to reduce exposure to dust or welding fume?

  • Controls may include:
    Windows up, roads/drill or shot pattern watered, dust suppression sprays in use, adequate distance from dust generating equipment (eg loading unit), use of wet cleaning methods or vacuum, clean surfaces, local exhaust ventilation or fans in use during welding, use of respirators, cabin door and window seals intact, cabin pressurisation.

  • Has the participant been scheduled for a fit test and have they attended and passed?

  • See the site Occ Health Nurse for attendance records.
    The fit test must be conducted for the respirator that the individual uses.

  • Is the person in adherence with the facial hair policy for site?

Dust - Tyre Fitter

  • Have airborne hazards been identified in the Take5/JHA and have controls been implemented to reduce exposure to dust or welding fume?

  • Controls may include:
    Windows up, roads/drill or shot pattern watered, dust suppression sprays in use, adequate distance from dust generating equipment (eg loading unit), use of wet cleaning methods or vacuum, clean surfaces, local exhaust ventilation or fans in use during welding, use of respirators, cabin door and window seals intact, cabin pressurisation.

  • Has the participant been scheduled for a fit test and have they attended and passed?

  • See the site Occ Health Nurse for attendance records.
    The fit test must be conducted for the respirator that the individual uses.

  • Is the person in adherence with the facial hair policy for site?

Hearing Protection

Hearing Protection - Shotfirer

  • Hearing protection question applies to all personnel interviewed.

  • no label
  • What hearing protection is the individual wearing or do they normally wear?

  • Correct type of hearing protection for SEG

  • Incorrect hearing protection for SEG - provide education for correct plugs/muffs

  • Is this correct type of hearing protection?

Hearing Protection - Shotfirer

  • Hearing protection question applies to all personnel interviewed.

  • no label
  • What hearing protection is the individual wearing or do they normally wear?

  • Correct type of hearing protection for SEG

  • Incorrect hearing protection for SEG - provide education for correct plugs/muffs

  • Is this correct type of hearing protection?

Hearing Protection - Driller

  • Hearing protection question applies to all personnel interviewed.

  • no label
  • What hearing protection is the individual wearing or do they normally wear?

  • Correct type of hearing protection for SEG

  • Incorrect hearing protection for SEG - provide education for correct plugs/muffs

  • Is this correct type of hearing protection?

Hearing Protection - Driller

  • Hearing protection question applies to all personnel interviewed.

  • no label
  • What hearing protection is the individual wearing or do they normally wear?

  • Correct type of hearing protection for SEG

  • Incorrect hearing protection for SEG - provide education for correct plugs/muffs

  • Is this correct type of hearing protection?

Hearing Protection - Daracon Crusher Operator

  • Hearing protection question applies to all personnel interviewed.

  • no label
  • What hearing protection is the individual wearing or do they normally wear?

  • Correct type of hearing protection for SEG

  • Incorrect hearing protection for SEG - provide education for correct plugs/muffs

  • Is this correct type of hearing protection?

Hearing Protection - Daracon Crusher Operator

  • Hearing protection question applies to all personnel interviewed.

  • no label
  • What hearing protection is the individual wearing or do they normally wear?

  • Correct type of hearing protection for SEG

  • Incorrect hearing protection for SEG - provide education for correct plugs/muffs

  • Is this correct type of hearing protection?

Hearing Protection - Boilermaker

  • Hearing protection question applies to all personnel interviewed.

  • no label
  • What hearing protection is the individual wearing or do they normally wear?

  • Correct type of hearing protection for SEG

  • Incorrect hearing protection for SEG - provide education for correct plugs/muffs

  • Is this correct type of hearing protection?

  • When they are air arc gouging do they wear double hearing protection? Class 5 plugs + Muffs?

Hearing Protection - Boilermaker

  • Hearing protection question applies to all personnel interviewed.

  • no label
  • What hearing protection is the individual wearing or do they normally wear?

  • Correct type of hearing protection for SEG

  • Incorrect hearing protection for SEG - provide education for correct plugs/muffs

  • Is this correct type of hearing protection?

  • When they are air arc gouging do they wear double hearing protection? Class 5 plugs + Muffs?

Hearing Protection - Tyre Fitter

  • Hearing protection question applies to all personnel interviewed.

  • no label
  • What hearing protection is the individual wearing or do they normally wear?

  • Correct type of hearing protection for SEG

  • Incorrect hearing protection for SEG - provide education for correct plugs/muffs

  • Is this correct type of hearing protection?

Hearing Protection - Tyre Fitter

  • Hearing protection question applies to all personnel interviewed.

  • no label
  • What hearing protection is the individual wearing or do they normally wear?

  • Correct type of hearing protection for SEG

  • Incorrect hearing protection for SEG - provide education for correct plugs/muffs

  • Is this correct type of hearing protection?

Hearing Protection - Dozer

  • Hearing protection question applies to all personnel interviewed.

  • no label
  • What hearing protection is the individual wearing or do they normally wear?

  • Correct type of hearing protection for SEG

  • Incorrect hearing protection for SEG - provide education for correct plugs/muffs

  • Is this correct type of hearing protection?

Hearing Protection - Dozer

  • Hearing protection question applies to all personnel interviewed.

  • no label
  • What hearing protection is the individual wearing or do they normally wear?

  • Correct type of hearing protection for SEG

  • Incorrect hearing protection for SEG - provide education for correct plugs/muffs

  • Is this correct type of hearing protection?

Hearing Protection - Truck

  • Hearing protection question applies to all personnel interviewed.

  • no label
  • What hearing protection is the individual wearing or do they normally wear?

  • Correct type of hearing protection for SEG

  • Incorrect hearing protection for SEG - provide education for correct plugs/muffs

  • Is this correct type of hearing protection?

Hearing Protection - Truck

  • Hearing protection question applies to all personnel interviewed.

  • no label
  • What hearing protection is the individual wearing or do they normally wear?

  • Correct type of hearing protection for SEG

  • Incorrect hearing protection for SEG - provide education for correct plugs/muffs

  • Is this correct type of hearing protection?

Hearing Protection - CHPP

  • Hearing protection question applies to all personnel interviewed.

  • no label
  • What hearing protection is the individual wearing or do they normally wear?

  • Correct type of hearing protection for SEG

  • Incorrect hearing protection for SEG - provide education for correct plugs/muffs

  • Is this correct type of hearing protection?

Hearing Protection - CHPP

  • Hearing protection question applies to all personnel interviewed.

  • no label
  • What hearing protection is the individual wearing or do they normally wear?

  • Correct type of hearing protection for SEG

  • Incorrect hearing protection for SEG - provide education for correct plugs/muffs

  • Is this correct type of hearing protection?

Hearing Protection - Maintenance

  • Hearing protection question applies to all personnel interviewed.

  • no label
  • What hearing protection is the individual wearing or do they normally wear?

  • Correct type of hearing protection for SEG

  • Incorrect hearing protection for SEG - provide education for correct plugs/muffs

  • Is this correct type of hearing protection?

  • Does the individual use class 5 hearing protection for high noise tasks? Eg rattle gun, grinder?

Hearing Protection - Maintenance

  • Hearing protection question applies to all personnel interviewed.

  • no label
  • What hearing protection is the individual wearing or do they normally wear?

  • Correct type of hearing protection for SEG

  • Incorrect hearing protection for SEG - provide education for correct plugs/muffs

  • Is this correct type of hearing protection?

  • Does the individual use class 5 hearing protection for high noise tasks? Eg rattle gun, grinder?

Hearing Protection - Field Maintenance/RAM

  • Hearing protection question applies to all personnel interviewed.

  • no label
  • What hearing protection is the individual wearing or do they normally wear?

  • Correct type of hearing protection for SEG

  • Incorrect hearing protection for SEG - provide education for correct plugs/muffs

  • Is this correct type of hearing protection?

  • Does the individual use class 5 hearing protection for high noise tasks? Eg rattle gun, grinder?

Hearing Protection - Field Maintenance/RAM

  • Hearing protection question applies to all personnel interviewed.

  • no label
  • What hearing protection is the individual wearing or do they normally wear?

  • Correct type of hearing protection for SEG

  • Incorrect hearing protection for SEG - provide education for correct plugs/muffs

  • Is this correct type of hearing protection?

  • Does the individual use class 5 hearing protection for high noise tasks? Eg rattle gun, grinder?

Vibration

  • Vibration CCMP applies to dozers and trucks only:
    - dozer ripping
    - truck loading

Vibration - Dozer

  • What is the equipment number?

  • Do operators demonstrate correct seating set up and adjustment?

  • Using IP18 n SAP, has the seat been changed out within the last 52 weeks as per schedule (CAT or ISRI seat)?

  • Using IW39 in SAP, has there been a Maintenance Order created in relation to *vibration* or *rough*. Has the Maintenance Order been completed/closed?

  • Has the operator adhered to the 2 hour limit for dozer ripping?<br>Are there enough breaks in the work for recovery during tasks with a risk of high vibration?<br>Has job rotation been implemented for tasks with risk of high vibration exposure?

Vibration - Dozer

  • What is the equipment number?

  • Do operators demonstrate correct seating set up and adjustment?

  • Using IP18 n SAP, has the seat been changed out within the last 52 weeks as per schedule (CAT or ISRI seat)?

  • Using IW39 in SAP, has there been a Maintenance Order created in relation to *vibration* or *rough*. Has the Maintenance Order been completed/closed?

  • Has the operator adhered to the 2 hour limit for dozer ripping?<br>Are there enough breaks in the work for recovery during tasks with a risk of high vibration?<br>Has job rotation been implemented for tasks with risk of high vibration exposure?

Vibration - Truck

  • What is the equipment number?

  • Do operators demonstrate correct seating set up and adjustment?

  • Using IP18 n SAP, has the seat been changed out within the last 52 weeks as per schedule (CAT or ISRI seat)?

  • Using IW39 in SAP, has there been a Maintenance Order created in relation to *vibration* or *rough*. Has the Maintenance Order been completed/closed?

Vibration - Truck

  • What is the equipment number?

  • Do operators demonstrate correct seating set up and adjustment?

  • Using IP18 n SAP, has the seat been changed out within the last 52 weeks as per schedule (CAT or ISRI seat)?

  • Using IW39 in SAP, has there been a Maintenance Order created in relation to *vibration* or *rough*. Has the Maintenance Order been completed/closed?

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.