Title Page
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Client / Site
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Conducted on
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Prepared by
At-Risk Behaviors
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Did you address any at-risk behaviors?
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Findings
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Add media
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Action plan to address
At-Risk Conditions
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Did you address any at-risk conditions?
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Findings
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Add media
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Action plan to address
Safe Behaviors Commended
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Did you commend any associates on exhibiting safe behavior?
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Findings
5s / Housekeeping / Amnesty
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Did you address any 5s / Housekeeping / Amnesty concerns?
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Findings
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Add media
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Action plan to address
Attend Stand-up
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Did you attend a Department stand-up?
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Safety Tip
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Notable Safety topics covered
GEMBA Walk
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Did you actively participate in the GEMBA Walk?
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Findings
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Follow-up action item(s)
Associate Job Shadowing
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Did you shadow an associate working in path?
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Safety concerns identified
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Associate Feedback
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Follow-up action item(s)
Safety Audit Shadowing
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Did you shadow an ISS Coach as they conducted SBA'S?
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Observations
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Areas of Opportunity Identified
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Action plan to address
ISS Incident Investigation Assistance
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Did you provide assistance in conducting an ISS Incident Investigation?
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Findings
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Action plan to address
Parking Lot Inspection
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Was a parking lot inspection completed?
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Findings
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Add media
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Action plan to address
PIT Audit
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Was a PIT Audit conducted?
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At-Risk behaviors identified & addressed
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Equipment Safety
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Add media
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5s / Housekeeping concerns identified
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Add media
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Action plan to address
Additional Findings / Concerns
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Did you have any additional comments/concerns that have not been addressed above?
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Findings
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Add media
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Follow-up action item(s)
