Information
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Name
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Date
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Site
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Area
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# of People Observed
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# of People Contacted
Acts
Reactions to People
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Adjusting Personal Protective Equipment?
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Changing Postion?
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Rearranging Job?
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Stopping Job?
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Attaching Grounds?
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Performing Locks?
Positions of People
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Striking Against or Being Struck by Objects
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Caught In, On, or Between Objects
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Falling
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Contacting Temperature Extremes
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Contacting Electric Current
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Inhaling, Absorbing, or Swallowing a Hazardous Substance
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Repetitive Motions
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Awkward Positions/Static Postures
Personal Protective Equipment
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Head
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Eyes and Face
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Ears
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Respiratory System
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Arms and Hands
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Trunk
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Legs and Feet
Tools and Equipment
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Right for the Job?
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Used Correctly?
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In Safe Condition?
Procedures
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Available?
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Adequate?
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Known?
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Understood?
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Followed?
Orderliness
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Known?
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Understood?
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Followed?
Observations
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REMEMBER-Do not mention the names of employes in this section!
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Unsafe Acts Observed
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REMEMBER-Do not mention the names of employes in this section!
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Safe Acts Observed
Conditions
Tools and Equipment
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Right for the job?
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In Safe Condition?
Structures and Work Area
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Clean?
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Orderly?
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Right for the job?
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In Safe Condition?
Environment
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Clean?
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Orderly?
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In Safe Condition?
Orderliness
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Neat and in good order?
Additional info
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REMEMBER-Do not mention the names of employees in this section!
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Additional information gathered from talking to employee.
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Time taken on audit
