Title Page
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Company
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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
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Location of Observation
Nature of Observation
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Health
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Safety
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Environment
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Near Miss
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Description of Obsevation
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Immediate Action Taken
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Further Actions Suggested
People
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Planning/ communication
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Procedure not enforced
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Positions / handling / Lifting
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Others
Work Environment
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Noise / Heat / Ventilation
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Lighting/ No barriers/ Signs
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Hygiene / Health
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Housekeeping
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Ergonomics
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Work Surface / Area
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Other
Tools and Equipments
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Selection / Use
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Condition / Maintenance
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Other
PPEs
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Head/ Face/ Eyes/ Ears
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Reflector
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Fall Protection
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Respiratory System
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Hands / Arms
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Trunk/ Feet/ Legs
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Other
Environment
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Trash not disposed
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Energy/ water waste
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Air emissions / spills
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Material incorrectly stored on labeled
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Other
Procedure and Training
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Unsuitable procedure
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Procedure not known
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Others
Positive Comments
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Positive comments
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Observer's Signature
