Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
Reactions of People - Check Box if Safe
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All Safe? If all safe move to next action
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Adjusting Personal Protective Equipment
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Number of Safe and Unsafe People
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Photo
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Notes
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Changing Position
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Number of Safe and Unsafe People
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Photo
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Notes
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Rearranging Job
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Number of Safe and Unsafe People
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Photo
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Notes
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Stopping Job
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Number of Safe and Unsafe People
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Photo
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Notes
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Attaching Grounds
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Number of Safe and Unsafe People
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Photo
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Notes
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Performing Lockouts
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Number of Safe and Unsafe People
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Photo
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Notes
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Mind Not on Task
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Number of Safe and Unsafe People
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Photo
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Notes
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Rushing
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Number of Safe and Unsafe People
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Photo
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Notes
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Frustration
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Number of Safe and Unsafe People
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Photo
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Notes
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Complacency
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Number of Safe and Unsafe People
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Photo
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Notes
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Fatigue
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Number of Safe and Unsafe People
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Photo
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Notes
Positions of People - Check Box if Safe
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All Safe? If all safe move to next action
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Striking Against or Being Struck by Objects
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Number of Safe and Unsafe People
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Photo
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Notes
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Caught In, On, or Between Objects
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Number of Safe and Unsafe People
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Photo
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Notes
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Falling
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Number of Safe and Unsafe People
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Photo
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Notes
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Contacting Temperature Extremes
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Number of Safe and Unsafe People
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Photo
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Notes
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Contacting Electric Current
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Number of Safe and Unsafe People
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Photo
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Notes
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Inhaling, Absorbing, or Swallowing a Hazardous Substances
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Number of Safe and Unsafe People
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Photo
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Notes
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Repetitive Motions
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Number of Safe and Unsafe People
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Photo
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Notes
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Awkward Positions/Static Postures
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Number of Safe and Unsafe People
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Photo
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Notes
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Eyes Not on Task
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Number of Safe and Unsafe People
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Photo
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Notes
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In Line of Fire
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Number of Safe and Unsafe People
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Photo
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Notes
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Balance/Traction/Grip
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Number of Safe and Unsafe People
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Photo
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Notes
Personal Protective Equipment - Check Box if Safe
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All Safe? If all safe move to next action
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Head
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Number of Safe and Unsafe People
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Photo
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Notes
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Eyes and Face
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Number of Safe and Unsafe People
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Photo
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Notes
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Ears
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Number of Safe and Unsafe People
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Photo
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Notes
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Respiratory System
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Number of Safe and Unsafe People
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Photo
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Notes
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Arms and Hands
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Number of Safe and Unsafe People
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Photo
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Notes
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Trunk
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Number of Safe and Unsafe People
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Photo
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Notes
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Legs and Feet
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Number of Safe and Unsafe People
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Photo
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Notes
Tools and Equipment - Check Box if Safe
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All Safe? If all safe move to next action
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Right for the Job
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Number of Safe and Unsafe People
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Photo
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Notes
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Used Correctly
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Number of Safe and Unsafe People
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Photo
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Notes
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In Safe Condition
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Number of Safe and Unsafe People
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Photo
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Notes
Procedures - Check Box if Safe
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All Safe? If all safe move to next action
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Available
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Number of Safe and Unsafe People
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Photo
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Notes
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Adequate
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Number of Safe and Unsafe People
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Photo
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Notes
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Known
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Number of Safe and Unsafe People
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Photo
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Notes
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Understood
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Number of Safe and Unsafe People
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Photo
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Notes
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Followed
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Number of Safe and Unsafe People
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Photo
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Notes
Housekeeping - Check Box if Safe
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All Safe? If all safe move to next action
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Standards Known
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Number of Safe and Unsafe People
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Photo
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Notes
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Standards Understood
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Number of Safe and Unsafe People
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Photo
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Notes
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Standards Followed
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Number of Safe and Unsafe People
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Photo
-
Notes
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Standards Available
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Number of Safe and Unsafe People
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Photo
-
Notes
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Standards Adequate
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Number of Safe and Unsafe People
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Photo
-
Notes
Structures and Work Area - Check Box if Safe
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All Safe? If all safe move to next condition
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Clean
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Number of Safe and Unsafe People
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Photo
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Notes
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Orderly
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Number of Safe and Unsafe People
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Photo
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Notes
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Right for the Job
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Number of Safe and Unsafe People
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Photo
-
Notes
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In Safe Condition
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Number of Safe and Unsafe People
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Photo
-
Notes
Environment - Check Box if Safe
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All Safe? If all safe move to next condition
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Clean
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Number of Safe and Unsafe People
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Photo
-
Notes
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Orderly
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Number of Safe and Unsafe People
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Photo
-
Notes
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In Safe Condition
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Number of Safe and Unsafe People
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Photo
-
Notes
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Safe Acts Observed
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Unsafe Acts Observed
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Name/Date/Area
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# People Contacted/# People Observed
