SAFETY EVALUATION FORM

• Client Evaluation Completed for

• Conducted on

  Date

• Prepared by

• Location

Guardian Safety Solutions

• Evaluation completed by:

• Evaluation of Employee Name:

• Date of evaluation:

  Date

Site of Evaluation:

• 1.1 Check Employee has relevant license

  Yes

  No

• 1.2 Check Employee has relevant permits 2

  Yes

  No

• 2.1 Check Employee complies with site attendance

  Yes

  No

• 2.2 Check Employee completed Safety Checklist in

  Yes

  No

• 3.1 Check employee completes all required paperwork

  Yes

  No

• 4.1 Check employee completed any site-specific doc before commencing work – eg JSA, SWMS,

  Yes

  No

• WPCG(attach photo)

  Media

• 4.2 Check employee follows SOP specific for the site 5

  Yes

  No

• 5.1 Check employee utilized all PPE specific for the site

  Yes

  No

• 5.2 Check employee sets work area as required for the specific site (attach photo)

  Yes

  No

• 5.3 Check employee complies with all site specific requirements

  Yes

  No

• 5.4 Check employee complies with Guardian Requirements

  Yes

  No

EDUCATION & TRAINING

FACILITY AUDIT / INSPECTION : LOCATION MANAGEMENT

PERSON PROTECTIVE EQUIPMENT| PRECAUTIONS

• OVERALL EVALUATION AND COMMENTS

• Employee Signature

  Sign

• Evaluators Signature

  Sign

ADM081_GSS_safety_evaluation_form (R. Aug 2023)