PTO / PGI Checklist

• Site conducted

  Select

• Employee Name and Department (completing checklist)

• Task / Area being observed

• Type of Observation

  Initial

  Follow-up

• Date and Time of observation

  Date

• Prepared by

• Location
  Address

General

• Reason for observation

  Select General Inspection Critical Task Incident repeat area, task or person Good performing area, task or person Poor performing area, task or person Other

  • General Inspection
  • Critical Task
  • Incident repeat area, task or person
  • Good performing area, task or person
  • Poor performing area, task or person
  • Other

• Specify

• Task Description

• Major / Primary steps required to complete task

Audit

• Is special PPE require?

  Yes

  No

  N/A

• Is Lock-Out required?

  Yes

  No

  N/A

• Is a Risk Assessment required?

  Yes

  No

  N/A

• Are there any special instructions from the supervisor for the employee for completing this task?

  Yes

  No

  N/A

• Is the SLAM completed correctly?

  Yes

  No

  N/A

• Is the Work Permit and DSTI completed correctly?

  Yes

  No

  N/A

• Could any of the observed practices / conditions result in property damage, personal injury or illness?

  *No

  Yes

  N/A

• If yes, describe

• Where the methods and practices observed the most efficient and productive?

  Yes

  No

  N/A

• If No, describe

• Did the practices observed comply with all of the applicable procedures or standards that exist for the task?

  Yes

  No

  N/A

• If No, describe

• Did you observe any practices or aspects of the task that where improvements which deserve recognition?

  Yes

  No

  N/A

• If yes, describe

• Describe bellow observed practices that require correction or improvement

• Have you corrected or complimented the worker base on these observations?

  Yes

  No

  N/A

• Should a follow up observation of this area, task or person take place?

  *No

  Yes

  N/A

• If yes, describe who and why ?

• Describe any standard procedures, methods or equipment you observed that should be changed in the interest of safety and / or productivity

Actions

• Details

• Who

• When

  Date
Inspection Participants

• Name and Signature

  Sign