Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Reactions of People - Check Box if Safe

  • All Safe? If all safe move to next action

  • Adjusting Personal Protective Equipment

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • Changing Position

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • Rearranging Job

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • Stopping Job

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • Attaching Grounds

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • Performing Lockouts

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • Mind Not on Task

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • Rushing

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • Frustration

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • Complacency

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • Fatigue

  • Number of Safe and Unsafe People

  • Photo

  • Notes

Positions of People - Check Box if Safe

  • All Safe? If all safe move to next action

  • Striking Against or Being Struck by Objects

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • Caught In, On, or Between Objects

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • Falling

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • Contacting Temperature Extremes

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • Contacting Electric Current

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • Inhaling, Absorbing, or Swallowing a Hazardous Substances

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • Repetitive Motions

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • Awkward Positions/Static Postures

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • Eyes Not on Task

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • In Line of Fire

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • Balance/Traction/Grip

  • Number of Safe and Unsafe People

  • Photo

  • Notes

Personal Protective Equipment - Check Box if Safe

  • All Safe? If all safe move to next action

  • Head

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • Eyes and Face

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • Ears

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • Respiratory System

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • Arms and Hands

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • Trunk

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • Legs and Feet

  • Number of Safe and Unsafe People

  • Photo

  • Notes

Tools and Equipment - Check Box if Safe

  • All Safe? If all safe move to next action

  • Right for the Job

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • Used Correctly

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • In Safe Condition

  • Number of Safe and Unsafe People

  • Photo

  • Notes

Procedures - Check Box if Safe

  • All Safe? If all safe move to next action

  • Available

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • Adequate

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • Known

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • Understood

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • Followed

  • Number of Safe and Unsafe People

  • Photo

  • Notes

Housekeeping - Check Box if Safe

  • All Safe? If all safe move to next action

  • Standards Known

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • Standards Understood

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • Standards Followed

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • Standards Available

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • Standards Adequate

  • Number of Safe and Unsafe People

  • Photo

  • Notes

Structures and Work Area - Check Box if Safe

  • All Safe? If all safe move to next condition

  • Clean

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • Orderly

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • Right for the Job

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • In Safe Condition

  • Number of Safe and Unsafe People

  • Photo

  • Notes

Environment - Check Box if Safe

  • All Safe? If all safe move to next condition

  • Clean

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • Orderly

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • In Safe Condition

  • Number of Safe and Unsafe People

  • Photo

  • Notes

  • Safe Acts Observed

  • Unsafe Acts Observed

  • Name/Date/Area

  • # People Contacted/# People Observed

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.