Title Page

  • Client / Site

  • Conducted on

  • Prepared by

At-Risk Behaviors

  • Did you address any at-risk behaviors?

  • Findings

  • Add media

  • Action plan to address

At-Risk Conditions

  • Did you address any at-risk conditions?

  • Findings

  • Add media

  • Action plan to address

Safe Behaviors Commended

  • Did you commend any associates on exhibiting safe behavior?

  • Findings

5s / Housekeeping / Amnesty

  • Did you address any 5s / Housekeeping / Amnesty concerns?

  • Findings

  • Add media

  • Action plan to address

Attend Stand-up

  • Did you attend a Department stand-up?

  • Safety Tip

  • Notable Safety topics covered

GEMBA Walk

  • Did you actively participate in the GEMBA Walk?

  • Findings

  • Follow-up action item(s)

Associate Job Shadowing

  • Did you shadow an associate working in path?

  • Safety concerns identified

  • Associate Feedback

  • Follow-up action item(s)

Safety Audit Shadowing

  • Did you shadow an ISS Coach as they conducted SBA'S?

  • Observations

  • Areas of Opportunity Identified

  • Action plan to address

ISS Incident Investigation Assistance

  • Did you provide assistance in conducting an ISS Incident Investigation?

  • Findings

  • Action plan to address

Parking Lot Inspection

  • Was a parking lot inspection completed?

  • Findings

  • Add media

  • Action plan to address

PIT Audit

  • Was a PIT Audit conducted?

  • At-Risk behaviors identified & addressed

  • Equipment Safety

  • Add media

  • 5s / Housekeeping concerns identified

  • Add media

  • Action plan to address

Additional Findings / Concerns

  • Did you have any additional comments/concerns that have not been addressed above?

  • Findings

  • Add media

  • Follow-up action item(s)

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.