Safety Contacts Form

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

SAFETY CONTACTS FORM

• Date / Time

  Date

• Location :

• Undertaken By :

• Person Observed :

• Summary of Safety Contact :

Checklist / Comments

• Overall, are you satisfied the person was working safely (I.e. check against the SOP or JSA)?

  Yes

  No

  N/A

• Had a risk assessment (Job Start Check, JSA) been done before the task was started?

  Yes

  No

  N/A

• Was the correct procedure being followed (refer to the SOP)?

  Yes

  No

  N/A

• Was the person in a safe position (I.e. not in the line of fire of potential hazards) ?

  Yes

  No

  N/A

• Was the required PPE being used?

  Yes

  No

  N/A

• Were the correct tools and equipment being used?

  Yes

  No

  N/A

• Was the equipment properly isolated and in accordance with site isolation SOP?

  Yes

  No

  N/A

• Was the standard of housekeeping appropriate to maintaining a safe work area?

  Yes

  No

  N/A

• Did this Safety Contact result in changes to the activity or actions being observed?

  Yes

  No

  N/A

Immediate Action Taken (including positive recognition or constructive feedback if given:

• Immediate Action Taken :

Follow Up Actions

• Follow Up Actions :

• Assigned to :

• Due Date :

• Entered into INX InControl (Operations - Inspections - Safety Contact) Ref No: