Information

  • Client / Site

  • Prepared by

  • Conducted on

  • Document No.

  • Task Being Observed

PERSONNEL

  • Comments

  • We're wearing PPE correctly upon arrival at the task site? (PPE was in good condition and was not fitted or dusted on arrival)

  • Comments

  • Identified all hazards relevant to the task?

  • Comments

  • Were working safely in accordance with task requirements? (START, JHA, SWP)

  • Comments

  • Were fit for work at the time of observation?

  • Comments

  • Were working using an approved isolation method?

  • Comments

  • Have been trained and deemed component to do the task?

  • Comments

  • Implemented all identified controls to manager risks?

  • Comments

  • Have been authorised/instructed to undertake the activity by their supervisor?

  • Comments

TOOLS AND EQUIPMENT

  • Are fit for purpose?

  • Comments

  • Are being used as per requirements (do not create hazards)?

  • Comments

  • Are in safe working order and tagged (where applicable)?

  • Comments

  • Are certified where applicable?

  • Comments

  • Will not require personnel to over-exert themselves to carry out the task?

  • Comments

WORK ENVIRONMENT

  • Is established so personnel are not in the line of fire from energy sources?

  • Comments

  • Housekeeping is of a high standard?

  • Comments

  • Enables safe ergonomic postures for the task?

  • Comments

  • Prevents personnel being able to fall from/to one level to another?

  • Comments

  • Design/layout prevents personnel from being exposed to nip points or rotating parts (guarding)?

  • Comments

PROCEDURE (Documents and Planning)

  • Permits to work are established where required to undertake the activity?

  • Comments

  • Risk assessments for task/s have been completed and appropriately recorded to identify the risks?

  • Comments

  • Agreed controls are implemented to manage risks (ref ORA or procedures)?

  • Comments

  • Emergency response procedures for the activity are known, accessible and current?

  • Comments

ORGANISATIONAL FACTORS

  • Task planning includes sufficient time and resources for the activity?

  • Comments

  • Change management process has been adequately applied where necessary?

  • Comments

  • Task/activity has been communicated to persons likely to be affected (PSI, etc)?

  • Comments

STANDOUT SAFE CONDITIONS/BEHAVIOURS OBSERVED

  • Comments

AT-RISK CONDITIONS/BEHAVIOURS IDENTIFIED

    At-Risk Condition/Behaviour
  • What was identified?

  • Immediate Action Taken

  • Corrective Actions

  • Action Required

  • By Who

  • By When

  • Cintellate No.

  • Supervisor Signature

Email to site admin and/or safety department.

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.