Title Page
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Project Name
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Client / Site
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Conducted on
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Auditor
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Location
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Personnel
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Answer the following questions based on the task and behaviors you observe regarding the use of their hands while working. If it doesn't apply, please put "N/A"
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Did the members of the work team identify the proper gloves on the JSA based on the job task
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Type of possible Injury
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Correction or Intervention
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Brief description of your good observations or intervention feedback to the worker or workers, (do not include specific names)
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Is the proper hand protection being used throughout these task?
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Type of Possible Injury
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Correction or Intervention
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Brief description of your good observations or intervention feedback to the worker or workers, (do not include specific names)
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Are the gloves being worn in a safe working condition? (Ex. worn or damaged)
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Type of Possible Injury
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Correction or Intervention
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Brief description of your good observations or intervention feedback to the worker or workers, (do not include specific names)
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If tools are necessary, are they in safe working condition? (Ex. altered, home-made, worn, broken, missing parts)
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Type of Possible Injury
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Correction or intervention
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Brief description of your good observations or intervention feedback to the worker or workers, (do not include specific names)
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Are tools being used safely? (ex. bad technique, improper tool for the job)
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Type of Possible Injury
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Correction or Intervention
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Brief description of your good observations or intervention feedback to the worker or workers, (do not include specific names)
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During the task, are workers keeping their hands out of the line of fire? (ex. both hand placement, not paying attention)
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Type of Possible Injury
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Correction or Intervention
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Brief description of your good observations or intervention feedback to the worker or workers, (do not include specific names)
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Can workers use means other than their hands to complete task safely? (ex. vice, c-clamps, tag lines, push pole, etc.)
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Type of Possible Injury
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Correction or Intervention
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Brief description of your good observations or intervention feedback to the worker or workers, (do not include specific names)
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Are there any hand hazards in the work area that was created as a result of the work? (ex. new hazards, housekeeping)
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Type of possible injury
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Correction or Intervention
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Brief description of your good observations or intervention feedback to the worker or workers, (do not include specific names)
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Are there any additional observations you noted that could be considered at-risk?
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Types of Possible Injury
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Correction or Intervention
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Brief description of your good observations or intervention feedback to the worker or workers, (do not include specific names)
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Auditor Signature
