Information

  • Document No.

  • Audit Title

  • Meeting Type

  • Purpose of the Meeting

  • Conducted on

  • PREPARED BY

SIGN IN LOG

TYPE OF MEETING (Sign everyone in first then choose the meeting type)

  • Was this a Monthly Sub Safety Committee Meeting?

  • Topic
  • Topic of discussion.

  • Topic leader

  • Name of leader

  • Was this a Weekly/Toolbox Safety Meeting?

  • Topic
  • Topic of discussion.

  • Topic leader

  • Name of leader

  • Was this a Weekly Sub Safety Committee Terminal Walk?

  • Please have each member or team(s) complete at least one MBJ3 Bi-Weekly Jobsite Inspection form.

  • Was this a Accident/Incident Review?

  • What type of accident or incident?

  • Date and time of accident/incident

  • Name and ROCIP badge number of the affected employee

  • Affected employee Job title (position)

  • Worker status

  • What is the temporary agency name?

  • Explain why your answer was N/A.

  • Highest level of treatment received.

  • Company name for affected worker

  • Specific location of accident/incident, for example: Column line 70A-C, Entry vestibule E17, etc.).

  • Describe the injury or illness, parts of body affected, and object/substance that directly injured or made affected employee ill.

  • Were there any witnesses?

  • Witness #1's Name

  • Was a statement taken?

  • Witness #1's Name

  • Was a statement taken?

  • Witness #2's Name

  • Was a statement taken?

  • Witness #1's Name

  • Was a statement taken?

  • Witness #2's Name

  • Was a statement taken?

  • Witness #3's Name

  • Was a statement taken?

  • What directly happened to cause the Accident/incident? Choose all that apply.

  • Was a person excessively fatigued, impaired, upset, bored, distracted or overwhelmed?

  • Human Engineering

  • Human - Machine Interface

  • Labels Need Improvement

  • Arrangement/Placement

  • Displays Need Improvement

  • Controls Need Improvement

  • Monitoring Alertness Need Improvement

  • Plant / Unit Differences

  • Excessive Lifting

  • Tools / Instruments Need Improvement

  • Work Environment

  • Housekeeping Needs Improvement

  • Hot / Cold

  • Wet / Slick

  • Lights Need Improvement

  • Noisy

  • Obstruction

  • Cramped Quarters

  • Equipment Guard Needs Improvement

  • High Radiation / Contamination

  • Rough Terrain

  • Complex System

  • Knowledge based decision required

  • Monitoring too many items

  • Non-Fault Tolerant System

  • Errors not detectable

  • Errors not recoverable

  • Work Direction

  • Preparation

  • No preparation

  • Work Package / Permit Needs improvement

  • JHA Briefing Needs Improvement

  • Walk-thru Needs Improvement

  • Scheduling Needs Improvement

  • Lock / Out Tag Out Needs Improvement

  • Fall Protection Needs Improvement

  • Selection of Worker

  • Not Qualified

  • Fatigued

  • Upset

  • Substance Abuse

  • Team Selection Needs Improvement

  • Supervision During Work

  • No Supervision

  • Crew Teamwork Needs Improvement

  • Should the person have had and used a written procedure but did not?

  • Human Engineering

  • Human - Machine Interface

  • Labels Need Improvement

  • Arrangement/Placement

  • Displays Need Improvement

  • Controls Need Improvement

  • Monitoring Alertness Need Improvement

  • Plant / Unit Differences

  • Excessive Lifting

  • Tools / Instruments Need Improvement

  • Work Environment

  • Housekeeping Needs Improvement

  • Hot / Cold

  • Wet / Slick

  • Lights Need Improvement

  • Noisy

  • Obstruction

  • Cramped Quarters

  • Equipment Guard Needs Improvement

  • High Radiation / Contamination

  • Rough Terrain

  • Complex System

  • Knowledge based decision required

  • Monitoring too many items

  • Non-Fault Tolerant System

  • Errors not detectable

  • Errors not recoverable

  • Procedures

  • Not Used / Not Followed

  • No Procedure

  • Procedure not available or inconvenient for use

  • Procedure difficult to use

  • Procedure used not required but should be

  • Wrong

  • Typo

  • Sequence wrong

  • Facts Wrong

  • Situation not covered

  • Wrong revision used

  • Second checker needed

  • Followed Incorrectly

  • Format confusing

  • > 1 step / action

  • Excess references

  • Multi unit references

  • Limits need improvement

  • Details need improvement

  • Data / computations wrong or incorrect

  • Graphics need improvement

  • No checkoff

  • Checkoff misused

  • Misused second check

  • Ambiguous instructions

  • Equipment Identification needs improvement

  • Work Direction

  • Preparation

  • No preparation

  • Work Package / Permit Needs improvement

  • JHA Briefing Needs Improvement

  • Walk-thru Needs Improvement

  • Scheduling Needs Improvement

  • Lock / Out Tag Out Needs Improvement

  • Fall Protection Needs Improvement

  • Selection of Worker

  • Not Qualified

  • Fatigued

  • Upset

  • Substance Abuse

  • Team Selection Needs Improvement

  • Supervision During Work

  • No Supervision

  • Crew Teamwork Needs Improvement

  • Was a mistake made while using a procedure?

  • Not Used / Not Followed

  • No Procedure

  • Procedure not available or inconvenient for use

  • Procedure difficult to use

  • Procedure used not required but should be

  • Wrong

  • Typo

  • Sequence wrong

  • Facts Wrong

  • Situation not covered

  • Wrong revision used

  • Second checker needed

  • Followed Incorrectly

  • Format confusing

  • > 1 step / action

  • Excess references

  • Multi unit references

  • Limits need improvement

  • Details need improvement

  • Data / computations wrong or incorrect

  • Graphics need improvement

  • No checkoff

  • Checkoff misused

  • Misused second check

  • Ambiguous instructions

  • Equipment Identification needs improvement

  • Were alarms or displays to recognize or to respond to a condition unavailable or misunderstood?

  • Human - Machine Interface

  • Labels Need Improvement

  • Arrangement/Placement

  • Displays Need Improvement

  • Controls Need Improvement

  • Monitoring Alertness Need Improvement

  • Plant / Unit Differences

  • Excessive Lifting

  • Tools / Instruments Need Improvement

  • Work Environment

  • Housekeeping Needs Improvement

  • Hot / Cold

  • Wet / Slick

  • Lights Need Improvement

  • Noisy

  • Obstruction

  • Cramped Quarters

  • Equipment Guard Needs Improvement

  • High Radiation / Contamination

  • Rough Terrain

  • Complex System

  • Knowledge based decision required

  • Monitoring too many items

  • Non-Fault Tolerant System

  • Errors not detectable

  • Errors not recoverable

  • Were displays, alarms, controls, tools, or equipment identified or operating improperly?

  • Training

  • No Training

  • Task not analyzed

  • Decided not to train

  • No learning objective

  • Missed required training

  • Understanding Needs Improvement

  • Learning objective needs improvement

  • Lesson plan needs improvement

  • Instruction needs improvement

  • Practice / repetition needs improvement

  • Testing needs improvement

  • Continuing training needs improvement

  • Procedures

  • Not Used / Not Followed

  • No Procedure

  • Procedure not available or inconvenient for use

  • Procedure difficult to use

  • Procedure used not required but should be

  • Wrong

  • Typo

  • Sequence wrong

  • Facts Wrong

  • Situation not covered

  • Wrong revision used

  • Second checker needed

  • Followed Incorrectly

  • Format confusing

  • > 1 step / action

  • Excess references

  • Multi unit references

  • Limits need improvement

  • Details need improvement

  • Data / computations wrong or incorrect

  • Graphics need improvement

  • No checkoff

  • Checkoff misused

  • Misused second check

  • Ambiguous instructions

  • Equipment Identification needs improvement

  • Human Engineering

  • Human - Machine Interface

  • Labels Need Improvement

  • Arrangement/Placement

  • Displays Need Improvement

  • Controls Need Improvement

  • Monitoring Alertness Need Improvement

  • Plant / Unit Differences

  • Excessive Lifting

  • Tools / Instruments Need Improvement

  • Work Environment

  • Housekeeping Needs Improvement

  • Hot / Cold

  • Wet / Slick

  • Lights Need Improvement

  • Noisy

  • Obstruction

  • Cramped Quarters

  • Equipment Guard Needs Improvement

  • High Radiation / Contamination

  • Rough Terrain

  • Complex System

  • Knowledge based decision required

  • Monitoring too many items

  • Non-Fault Tolerant System

  • Errors not detectable

  • Errors not recoverable

  • Did the person need more skill/knowledge to perform the job or to respond to conditions or to understand system responses?

  • Training

  • No Training

  • Task not analyzed

  • Decided not to train

  • No learning objective

  • Missed required training

  • Understanding Needs Improvement

  • Learning objective needs improvement

  • Lesson plan needs improvement

  • Instruction needs improvement

  • Practice / repetition needs improvement

  • Testing needs improvement

  • Continuing training needs improvement

  • Work Direction

  • Preparation

  • No preparation

  • Work Package / Permit Needs improvement

  • JHA Briefing Needs Improvement

  • Walk-thru Needs Improvement

  • Scheduling Needs Improvement

  • Lock / Out Tag Out Needs Improvement

  • Fall Protection Needs Improvement

  • Selection of Worker

  • Not Qualified

  • Fatigued

  • Upset

  • Substance Abuse

  • Team Selection Needs Improvement

  • Supervision During Work

  • No Supervision

  • Crew Teamwork Needs Improvement

  • Was the work performed in an adverse environment? (such as hot, humid, dark, cramped, or hazardous)

  • Human - Machine Interface

  • Labels Need Improvement

  • Arrangement/Placement

  • Displays Need Improvement

  • Controls Need Improvement

  • Monitoring Alertness Need Improvement

  • Plant / Unit Differences

  • Excessive Lifting

  • Tools / Instruments Need Improvement

  • Work Environment

  • Housekeeping Needs Improvement

  • Hot / Cold

  • Wet / Slick

  • Lights Need Improvement

  • Noisy

  • Obstruction

  • Cramped Quarters

  • Equipment Guard Needs Improvement

  • High Radiation / Contamination

  • Rough Terrain

  • Complex System

  • Knowledge based decision required

  • Monitoring too many items

  • Non-Fault Tolerant System

  • Errors not detectable

  • Errors not recoverable

  • Did work involve repetitive motion, uncomfortable positions, vibrations, or heavy lifting?

  • Training

  • No Training

  • Task not analyzed

  • Decided not to train

  • No learning objective

  • Missed required training

  • Understanding Needs Improvement

  • Learning objective needs improvement

  • Lesson plan needs improvement

  • Instruction needs improvement

  • Practice / repetition needs improvement

  • Testing needs improvement

  • Continuing training needs improvement

  • Work Direction

  • Preparation

  • No preparation

  • Work Package / Permit Needs improvement

  • JHA Briefing Needs Improvement

  • Walk-thru Needs Improvement

  • Scheduling Needs Improvement

  • Lock / Out Tag Out Needs Improvement

  • Fall Protection Needs Improvement

  • Selection of Worker

  • Not Qualified

  • Fatigued

  • Upset

  • Substance Abuse

  • Team Selection Needs Improvement

  • Supervision During Work

  • No Supervision

  • Crew Teamwork Needs Improvement

  • Human Engineering

  • Human - Machine Interface

  • Labels Need Improvement

  • Arrangement/Placement

  • Displays Need Improvement

  • Controls Need Improvement

  • Monitoring Alertness Need Improvement

  • Plant / Unit Differences

  • Excessive Lifting

  • Tools / Instruments Need Improvement

  • Work Environment

  • Housekeeping Needs Improvement

  • Hot / Cold

  • Wet / Slick

  • Lights Need Improvement

  • Noisy

  • Obstruction

  • Cramped Quarters

  • Equipment Guard Needs Improvement

  • High Radiation / Contamination

  • Rough Terrain

  • Complex System

  • Knowledge based decision required

  • Monitoring too many items

  • Non-Fault Tolerant System

  • Errors not detectable

  • Errors not recoverable

  • This must be a team performance issue. Questions moving forward will be directed at team performance.

  • Did verbal communications or shift change play a role in this problem?

  • No communication or not timely

  • Communication System needs improvement

  • Late communication

  • Turnover needs improvement

  • No standard turnover process

  • Turnover process not used

  • Turnover process needs improvement

  • Misunderstood verbal communications

  • Standard terminology not used

  • Standard terminology needs improvement

  • Repeat back not used

  • Long message

  • Noisy environment

  • Did failure to agree about the who/what/when/where of performing the job play a role in this operation?

  • Communications

  • No communication or not timely

  • Communication System needs improvement

  • Late communication

  • Turnover needs improvement

  • No standard turnover process

  • Turnover process not used

  • Turnover process needs improvement

  • Misunderstood verbal communications

  • Standard terminology not used

  • Standard terminology needs improvement

  • Repeat back not used

  • Long message

  • Noisy environment

  • Work Direction

  • Preparation

  • No preparation

  • Work Package / Permit Needs improvement

  • JHA Briefing Needs Improvement

  • Walk-thru Needs Improvement

  • Scheduling Needs Improvement

  • Lock / Out Tag Out Needs Improvement

  • Fall Protection Needs Improvement

  • Selection of Worker

  • Not Qualified

  • Fatigued

  • Upset

  • Substance Abuse

  • Team Selection Needs Improvement

  • Supervision During Work

  • No Supervision

  • Crew Teamwork Needs Improvement

  • Training

  • No Training

  • Task not analyzed

  • Decided not to train

  • No learning objective

  • Missed required training

  • Understanding Needs Improvement

  • Learning objective needs improvement

  • Lesson plan needs improvement

  • Instruction needs improvement

  • Practice / repetition needs improvement

  • Testing needs improvement

  • Continuing training needs improvement

  • Was communication needed across organizational boundaries?

  • No communication or not timely

  • Communication System needs improvement

  • Late communication

  • Turnover needs improvement

  • No standard turnover process

  • Turnover process not used

  • Turnover process needs improvement

  • Misunderstood verbal communications

  • Standard terminology not used

  • Standard terminology needs improvement

  • Repeat back not used

  • Long message

  • Noisy environment

  • This must be a management system issue. Questions moving forward will be directed at this system.

  • Was a task performed in a hurry or a shortcut used?

  • Management System

  • Standards, Policies, or Administrative Controls (SPAC) need improvement

  • No SPAC

  • Not strict enough

  • Confusing or incomplete

  • Technical error

  • Drawing / print needs improvement

  • Standards, Policies, or Administrative Controls (SPAC) not used.

  • Communication of SPAC needs improvement

  • Recently changed

  • Enforcement needs improvement

  • No way to implement

  • Accountability needs improvement

  • Oversight / Employee Relations

  • Infrequent audits & evaluations

  • Audits & evaluations lack depth

  • Audits & evaluations not independent

  • Employee communications need improvement

  • Employee feedback needs improvement

  • Corrective Action

  • Corrective action needs improvement

  • Corrective action not yet implemented

  • Trending needs improvement

  • Work Direction

  • Preparation

  • No preparation

  • Work Package / Permit Needs improvement

  • JHA Briefing Needs Improvement

  • Walk-thru Needs Improvement

  • Scheduling Needs Improvement

  • Lock / Out Tag Out Needs Improvement

  • Fall Protection Needs Improvement

  • Selection of Worker

  • Not Qualified

  • Fatigued

  • Upset

  • Substance Abuse

  • Team Selection Needs Improvement

  • Supervision During Work

  • No Supervision

  • Crew Teamwork Needs Improvement

  • Had management been warned of this problem or had it happened before?

  • Standards, Policies, or Administrative Controls (SPAC) need improvement

  • No SPAC

  • Not strict enough

  • Confusing or incomplete

  • Technical error

  • Drawing / print needs improvement

  • Standards, Policies, or Administrative Controls (SPAC) not used.

  • Communication of SPAC needs improvement

  • Recently changed

  • Enforcement needs improvement

  • No way to implement

  • Accountability needs improvement

  • Oversight / Employee Relations

  • Infrequent audits & evaluations

  • Audits & evaluations lack depth

  • Audits & evaluations not independent

  • Employee communications need improvement

  • Employee feedback needs improvement

  • Corrective Action

  • Corrective action needs improvement

  • Corrective action not yet implemented

  • Trending needs improvement

  • Were policies, administrative controls, or procedures not used, missing, or in need of improvement?

  • Management System

  • Standards, Policies, or Administrative Controls (SPAC) need improvement

  • No SPAC

  • Not strict enough

  • Confusing or incomplete

  • Technical error

  • Drawing / print needs improvement

  • Standards, Policies, or Administrative Controls (SPAC) not used.

  • Communication of SPAC needs improvement

  • Recently changed

  • Enforcement needs improvement

  • No way to implement

  • Accountability needs improvement

  • Oversight / Employee Relations

  • Infrequent audits & evaluations

  • Audits & evaluations lack depth

  • Audits & evaluations not independent

  • Employee communications need improvement

  • Employee feedback needs improvement

  • Corrective Action

  • Corrective action needs improvement

  • Corrective action not yet implemented

  • Trending needs improvement

  • Work Direction

  • Preparation

  • No preparation

  • Work Package / Permit Needs improvement

  • JHA Briefing Needs Improvement

  • Walk-thru Needs Improvement

  • Scheduling Needs Improvement

  • Lock / Out Tag Out Needs Improvement

  • Fall Protection Needs Improvement

  • Selection of Worker

  • Not Qualified

  • Fatigued

  • Upset

  • Substance Abuse

  • Team Selection Needs Improvement

  • Supervision During Work

  • No Supervision

  • Crew Teamwork Needs Improvement

  • Procedures

  • Not Used / Not Followed

  • No Procedure

  • Procedure not available or inconvenient for use

  • Procedure difficult to use

  • Procedure used not required but should be

  • Wrong

  • Typo

  • Sequence wrong

  • Facts Wrong

  • Situation not covered

  • Wrong revision used

  • Second checker needed

  • Followed Incorrectly

  • Format confusing

  • > 1 step / action

  • Excess references

  • Multi unit references

  • Limits need improvement

  • Details need improvement

  • Data / computations wrong or incorrect

  • Graphics need improvement

  • No checkoff

  • Checkoff misused

  • Misused second check

  • Ambiguous instructions

  • Equipment Identification needs improvement

  • Should an independent quality control check caught the problem.

  • No Inspection

  • Inspection not required

  • No hold point

  • Hold point not performed

  • QC Needs Improvement

  • Inspection instructions need improvement

  • Inspection techniques need improvement

  • Foreign material exclusion during work needs improvement

  • If you haven't figured it out by now then the work was just an idiot, LOL!!!!

  • Describe the corrective action taken

  • Include all pictures

  • Explain the special case

  • Include all pictures

  • Explain in detail what property was damaged

  • Rate potential severity for injury based on the sequence of events for this incident.

  • Add pictures that show location and near miss event.

  • Rate potential severity for injury based on the sequence of events for this incident.

  • A citation must be given for this infraction.

  • Name(s), ROCIP badge number(s) and explanation of citation(s) of all those receiving a citation.

  • Explain the near miss in detail.

  • Describe corrective or additional corrective action taken

  • Was this another type of meeting?

  • Describe the type and content of the meeting.

SIGN IN SHEET

  • Use this for Weekly/Toolbox Safety Meetings only!

  • Name of Weekly/toolbox Meeting Attendee
  • Take picture of ROCIP Badge.

  • Add signature

  • Use this for all meetings involving the Safety Committee members only!

  • Attendee
  • Name of Attendee

  • Cell Phone: 903-220-2176, Email:salome@lantekavc.com

  • Salome Macias

  • Cell Phone: 214-577-0053, Email:francisco@hpenvirovision.com

  • Francisco Rangel

  • Cell Phone: 469-500-0817, Email: plara@osburncontractors.com

  • Paul Pina

  • Cell Phone: Email- Adonis_amaya1995@icloud.com

  • Jose Amaya

  • Trey Foster

  • Cell Phone: 214-790-3233: Email- tbohannon@dynamicsystemsusa.com

  • Tim Bohannon

  • Cell Phone: 214-425-8999: Email- daniel.james@thestcgroup.com

  • Daniel James

  • Cell Phone-214-918-6612: Email- Daniel@hpenvirovision.com.com

  • Daniel Flores

  • Cell Phone-972-800-0428: Email- oumana@sw-construction.com

  • Oscar Umana

  • Cell Phone-940-232-0740: Email- Darrell.bird@northstarfire.com

  • Darrel Bird

  • Cell Phone-214-907-0966: Email- jerry.newby@denalics.com

  • Jerry Newby

  • Cell Phone-469-865-4983: Email- richard.frame@siemens.com

  • Rick Frame

  • Cell Phone-817-948-6661: Email- msample@dynamicsystemsusa.com.com

  • Michael Sample

  • Cell Phone-214-418-8537: Email- rjones@elogicinc.net

  • Robert Jones

  • Cell Phone-817-201-6788: Email- rarredondo@manhattanconstruction.com

  • Robert Arredondo

  • Cell Phone-214-243-0026: Email- George@gentzlerelectric.com

  • George Guzman

  • Cell Phone-214-490-5544: Email- jarred@gentzlerelectric.com.com

  • Jarrad Quilty

  • Cell Phone-214-677-6326: Email- bpowers@manhattanconstruction.com

  • Bryce Powers

  • Cell Phone-254-577-9434: Email- chris.robertson@mcdean.com

  • Chris Robertson

  • Cell Phone-214-766-3475: Email- cindy.brummett@denalics.com

  • Cindy Brummett

  • Cell Phone-214-325-4402: Email- cmagers@manhattanconstruction.com

  • Cleve Magers

  • Cell Phone-214-869-7546: Email- franciscozepeda@marekbros.com

  • Francisco Zepeda

  • Cell Phone-469-803-6765: Email- jcornelius@manhattanconstruction.com

  • John Cornelius

  • Cell Phone-817-550-7270: Email- jlopez@manhattanconstruction.com

  • Juan Lopez

  • Cell Phone-214-799-9880: Email- Julie@skyebuild.com

  • Julie Watson

  • Cell Phone-214-529-2671: Email- mgates@sw-construction.com

  • Matt Gates

  • Cell Phone-325-201-8516: Email- aosmoot64@gmail.com

  • Odean Smoot

  • Cell Phone-972-595-4455: Email- rescovedo@walkertx.com

  • Richard Escovedo

  • Cell Phone-817-223-1105: Email- zheadden@burlesonelectric.net.com

  • Zac Headden

  • Cell Phone-469-408-0755: Email- rwright@VESDFW.com

  • Robert Wright

  • Cell Phone-214-808-0787: Email- amendoza@phillipsmay.com

  • Alex Mendoza

  • Cell Phone-214-717-1298: Email- yjimenez@carrcopainting.com

  • Yuritzi Jimenez

  • Cell Phone-972-802-0500: Email- jbisballe@natlfire.com

  • Jeff Bisballe

  • Cell Phone-972-439-4910: Email- sal@rndicompanies.com

  • Sal Inzillo

  • Add signature

  • Company Name

  • Company Name

  • Cell phone / ROCIP Badge #

  • Email address / Other information

  • Use this as the sign-in for all other meetings!
  • Add signature

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.