LF Interaction Form

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Select date

  Date

1.0 Procedure

• 1.1 SWP applied & followed

  Safe

  At Risk

  N/A

• 1.2 Task included in JHA

  Yes

  No

  N/A

• 1.3 Does the Take 5 identify all hazards

  Safe

  At Risk

  N/A

• 1.4 Have all the controls been put in place

  Safe

  At Risk

  N/A

• 1.5 Are the Isolations adequate

  Safe

  At Risk

  N/A

• 1.6 Are the permits in place adequate

  Safe

  At Risk

  N/A

• 1.7 Equipment pre-starts done

  Safe

  At Risk

  N/A

2.0 PPE

• 2.1 Head eyes & face

  Safe

  At Risk

  N/A

• 2.2 Hearing

  Safe

  At Risk

  N/A

• 2.3 Respiratory

  Safe

  At Risk

  N/A

• 2.4 Hand, body, foot

  Safe

  At Risk

  N/A

• 2.5 Fall arrest, restraint

  Safe

  At Risk

  N/A

3.0 Body Position/Use of Body

• 3.1 Line of fire

  Safe

  At Risk

  N/A

• 3.2 Lifting one side of body

  Safe

  At Risk

  N/A

• 3.3 Lifting excessive weights

  Safe

  At Risk

  N/A

• 3.4 Pushing & pulling

  Safe

  At Risk

  N/A

• 3.5 Reaching vertically

  Safe

  At Risk

  N/A

• 3.6 Reaching horizontally

  Safe

  At Risk

  N/A

• 3.7 Climbing

  Safe

  At Risk

  N/A

• 3.8 Pinch points

  Safe

  At Risk

  N/A

• 3.9 Cramped or awkward position

  Safe

  At Risk

  N/A

4.0 Tools & Equipment

• 4.1 Selection

  Safe

  At Risk

  N/A

• 4.2 Condition

  Safe

  At Risk

  N/A

• 4.3 Use

  Safe

  At Risk

  N/A

5.0 Working Environment

• 5.1 Housekeeping/storage

  Safe

  At Risk

  N/A

• 5.2 Barricades/signage

  Safe

  At Risk

  N/A

• 5.3 Stable level ground/work platform

  Safe

  At Risk

  N/A

• 5.4 Access/egress

  Safe

  At Risk

  N/A

• 5.5 Overhead power line corridor

  Safe

  At Risk

  N/A

6.0 Communication

• 6.1 Radio

  Safe

  At Risk

  N/A

• 6.2 Operation

  Safe

  At Risk

  N/A

7.0 Vehicles

• 7.1 Pre-start checks current

  Safe

  At Risk

  N/A

• 7.2 Condition

  Safe

  At Risk

  N/A

• 7.3 Operation

  Safe

  At Risk

  N/A

8.0 Enviroment

• 8.1 Procedure considers the environment

  Safe

  At Risk

  N/A

• 8.2 Hydrocarbon spills/leaks

  Safe

  At Risk

  N/A

• 8.3 Dust

  Safe

  At Risk

  N/A

• 8.4 Ore spillage

  Safe

  At Risk

  N/A

• 8.5 Nuisance noise to buildings

  Safe

  At Risk

  N/A

• 8.6 Waste segregation

  Safe

  At Risk

  N/A

• 8.7 Sediment control

  Safe

  At Risk

  N/A

• 8.8 Water conservation

  Safe

  At Risk

  N/A

9.0 Other hazards

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