SAFETY AUDIT FORM

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

CATEGORY A - PERSONAL PROTECTIVE EQUIPMENT

• EYES AND FACE

  Yes

  No

  N/A

• EARS

  Yes

  No

  N/A

• HEAD

  Yes

  No

  N/A

• HANDS AND ARMS

  Yes

  No

  N/A

• FEET AND LEGS

  Yes

  No

  N/A

• RESPIRATORY SYSTEM

  Yes

  No

  N/A

• TRUNK

  Yes

  No

  N/A

CATEGORY B - POSITIONS OF PEOPLESTRIKING

• STRIKING AGAINST

  Yes

  No

  N/A

• STRUCK BY

  Yes

  No

  N/A

• CAUGHT BETWEEN

  Yes

  No

  N/A

• FALLING

  Yes

  No

  N/A

• TEMPERATURE EXTREMES

  Yes

  No

  N/A

• ELECTRICAL CURRENT

  Yes

  No

  N/A

• INHALING

  Yes

  No

  N/A

• ABSORBING

  Yes

  No

  N/A

CATEGORY C - REACTIONS OF PEOPLE

• ADJUSTING PERSONAL - PROTECTIVE EQUIPMENT

  Yes

  No

  N/A

• CHANGING POSITIONS

  Yes

  No

  N/A

• REARRANGING JOB

  Yes

  No

  N/A

• STOPPING JOB

  Yes

  No

  N/A

• ATTACHING GROUNDS

  Yes

  No

  N/A

• HIDING, DODGING

  Yes

  No

  N/A

• CHANGING TOOLS

  Yes

  No

  N/A

CATEGORY D - TOOLS AND EQUIPMENT

• RIGHT FOR JOB?

  Yes

  No

  N/A

• USED CORRECTLY?

  Yes

  No

  N/A

• IN SAFE CONDITION?

  Yes

  No

  N/A

• SEAT BELTS IN USE?

  Yes

  No

  N/A

• BARRICADES OR WARNING LIGHTS?

  Yes

  No

  N/A

• CHOCKS/RESTRAINTS PROPERLY USED?

  Yes

  No

  N/A

CATEGORY E - PROCEDURES

• IS STANDARD PRACTICE ADEQUATE FOR JOB?

  Yes

  No

  N/A

• IS STANDARD PRACTICE ESTABLISHED?

  Yes

  No

  N/A

• IS STANDARD PRACTICE BEING MAINTAINED?

  Yes

  No

  N/A

• WORK PERMIT PROPER?

  Yes

  No

  N/A

• FIRE WATCH ADEQUATE?

  Yes

  No

  N/A

• GAS TEST (if needed) SATSIFACTORY?

  Yes

  No

  N/A

CATEGORY F - ORDERLINESS

• STANDARDS ESTABLISHED?

  Yes

  No

  N/A

• STANDARDS UNDERSTOOD?

  Yes

  No

  N/A

• OBSTRUCTION IN PASSAGEWAYS

  Yes

  No

  N/A

• DISORGANIZED TOOLS, MATERIALS

  Yes

  No

  N/A

• OBSTRUCTIONS BY STAIRS/PLATFORMS

  Yes

  No

  N/A

NOTES