Title Page
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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
Job Task
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Details
Personnel
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Personnel
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Personnel
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Personnel
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Personnel
Plan
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Describe the plan for your team:
Potential Hazards (check all that apply)
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Adverse Conditions
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Birds/Insects
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Chemical
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Cold
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Confined Space
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Crushing/Pinch Points
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Electrical Shock
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Ergonomic
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Fall From Heights
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Heat
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Heavy Lifting
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Hot Work
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Human Factors
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Mechanical Hazards
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Overhead Work
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Pressure
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Sharp/Protruding Objects
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Slips/Trips/Falls
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Sudden Release of Pressure
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Other Hazards
PPE
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Eye Protection
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Hand Protection
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Hot Gloves
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Personal Medical Bag (7lbs)
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FR Clothing
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Head Protection
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Face Sheild
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Fall Protection
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Foot Protection
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Are both safety "Step Up" straps attached to your harness?
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What loop does your hook go through for the straps to be effective?
Emergency Plan
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Do you have cell phone coverage?
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Name and address of nearest medical falcilty
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Directions
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Nearest Intersection