Information
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Client / Site
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Prepared by
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Conducted on
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Document No.
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Task Being Observed
PERSONNEL
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Comments
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We're wearing PPE correctly upon arrival at the task site? (PPE was in good condition and was not fitted or dusted on arrival)
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Comments
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Identified all hazards relevant to the task?
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Comments
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Were working safely in accordance with task requirements? (START, JHA, SWP)
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Comments
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Were fit for work at the time of observation?
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Comments
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Were working using an approved isolation method?
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Comments
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Have been trained and deemed component to do the task?
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Comments
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Implemented all identified controls to manager risks?
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Comments
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Have been authorised/instructed to undertake the activity by their supervisor?
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Comments
TOOLS AND EQUIPMENT
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Are fit for purpose?
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Comments
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Are being used as per requirements (do not create hazards)?
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Comments
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Are in safe working order and tagged (where applicable)?
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Comments
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Are certified where applicable?
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Comments
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Will not require personnel to over-exert themselves to carry out the task?
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Comments
WORK ENVIRONMENT
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Is established so personnel are not in the line of fire from energy sources?
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Comments
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Housekeeping is of a high standard?
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Comments
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Enables safe ergonomic postures for the task?
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Comments
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Prevents personnel being able to fall from/to one level to another?
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Comments
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Design/layout prevents personnel from being exposed to nip points or rotating parts (guarding)?
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Comments
PROCEDURE (Documents and Planning)
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Permits to work are established where required to undertake the activity?
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Comments
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Risk assessments for task/s have been completed and appropriately recorded to identify the risks?
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Comments
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Agreed controls are implemented to manage risks (ref ORA or procedures)?
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Comments
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Emergency response procedures for the activity are known, accessible and current?
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Comments
ORGANISATIONAL FACTORS
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Task planning includes sufficient time and resources for the activity?
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Comments
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Change management process has been adequately applied where necessary?
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Comments
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Task/activity has been communicated to persons likely to be affected (PSI, etc)?
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Comments
STANDOUT SAFE CONDITIONS/BEHAVIOURS OBSERVED
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Comments
AT-RISK CONDITIONS/BEHAVIOURS IDENTIFIED
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At-Risk Condition/Behaviour
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What was identified?
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Immediate Action Taken
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Corrective Actions
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Action Required
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By Who
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By When
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Cintellate No.
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Supervisor Signature