Title Page
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Location of Gemba Walk
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Prepared by
Operational Items
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Machines in the area are equipped with standard machine guarding where necessary and secured in place to prevent unsafe access to the Point of Operation?
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Have you instructed the operator stop the equipment and Lock Out until guards are reinstalled?
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Any body part of the employee(s) observed inside of equipment not locked out?
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The housekeeping of the area is maintained? (hoses rolled up, no debris on ground, spills/leaks are cleaned up, broken glass is swept up, ect.)
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Housekeeping Issue Before
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Housekeeping Issue Resolved
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Employees are properly wearing company issued PPE?
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Instruct employee on the Plant PPE Requirements and issue discipline.
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SIF Focus (Select Month)
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Work at Height
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SIF Issue(s) found?
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Describe Issue:
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Describe what was immediately done to correct the behavior or condition
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Describe positive feedback observed during your walk as it relates to SIF or any observation
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Electrical Safety
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Powered Industrial Vehicles
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Hot Work
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Any additional concerns or issues brought up by employees on the floor?
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Describe Issue
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Immediate fix:
