• Document No.

  • Conducted on

  • LOB & District Numbers, City & State Names

  • Marketplace

  • Customer Name

  • Location of system check - select from locator icon

Work Plan Compliance Review

  • Does the work plan identify journey management and DOT required information?

  • Does the work plan identify appropriate PPE and has the work site assessment been completed?

  • Has the visitors communication guide and critical activities section been completed?

  • Does the work plan list all activity & reference documents for the day?

  • Does the JSA section identify appropriate steps, hazards, hierarchy of controls, and mitigation steps?

  • Have all employees on location and all visitors to the location signed the work plan?

Work Plan Communication Review?

  • Did the employee sharing information use the communication guide while talking with you?

  • Did the employee sharing information ensure you had appropriate PPE to visit the location?

  • Was the JSA section, steps, hazards, hierarchy of controls, and mitigation steps reviewed with you?

  • Did the employee sharing information request that you repeat hazards and mitigation steps back to you?

  • Were identified reference documents available for review?

  • Can other employees on location communicate the hazards and mitigation as written and did they participate in the development process?

Work Observation Review

  • Were employees working according to the documented work activity for the day?

  • Were employees using documented mitigation for hazards identified on the work plan?

  • If a critical activity has been identified has the supervisor been notified or is a supervisor on site as identified on the work plan?

  • Were employees actively communicating while performing each job task observed?

  • Did management or the supervisor use positive reinforcement for safe behavior observed?

Best Practices Identified While On Location

  • Picture of best practices identified

  • Comment supporting best practice pictures

  • Drivers Signature:

  • Auditors Signature

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.