Safety Inspection

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Observer Name:

• Date and time of the Audit:

  Date
• Site and Location:
  Address

• Employee’s Dept:

• Employee Type:

• Observation Condition:

  Normal

  Shutdown

  Breakdown

• Has the employee been observed by someone else this month?

  Yes

  No

  N/A

All About your Task

• Please provide a brief description about your current task:

• What are the main hazard or risk associated with your task?

• What do you do to prevent accidents when you are doing this task?

  Follow Safety Precaution

  Nothing

  I don't know

• Is your workplace equipped with safety hazards?

  Yes

  No

  N/A

• Do you have any health or safety issues on your department?

  Yes

  No

  N/A

• Does this issues being addressed by your company right away?

  Yes

  No

  N/A

• With your current job, do you fee there's a need to deviate safety procedures?

  Yes

  No

  N/A

Below are the lists of behaviors that you can observe in your workplace. Select all that you think is safe in your working environment.

• Body Position

  Select Line of Fire Eyes on Path Eyes on Task Ascending / Decending Pinch Points / Rotating Objects

  • Line of Fire
  • Eyes on Path
  • Eyes on Task
  • Ascending / Decending
  • Pinch Points / Rotating Objects

• Manual Handling / Ergonomics

  Select Lifting / Lowering Twisting Pushing / Pulling Posture / Overextended / Cramped Response to Ergonomic Risk

  • Lifting / Lowering
  • Twisting
  • Pushing / Pulling
  • Posture / Overextended / Cramped
  • Response to Ergonomic Risk

• Tools & Equipment

  Select Tool/Equipment Selection Tool/Equipment Condition Tool/Equipment Use Guarding / Barricades / Delineation

  • Tool/Equipment Selection
  • Tool/Equipment Condition
  • Tool/Equipment Use
  • Guarding / Barricades / Delineation

• Procedures

  Select Take 5 / JHA / Prestart Isolation / Tag-out Communication of Hazards Permits Light Vehicle Operations Surface Mobile Equipment Lifting Equipment Explosives Work at Height Confined Space Entry

  • Take 5 / JHA / Prestart
  • Isolation / Tag-out
  • Communication of Hazards
  • Permits
  • Light Vehicle Operations
  • Surface Mobile Equipment
  • Lifting Equipment
  • Explosives
  • Work at Height
  • Confined Space Entry

• Work Environment

  Select Walking / Working Surfaces Housekeeping / Storage Lighting Temperature Extremes / UVR Exposure Liquid Transfer / Uncontrolled Discharge Hazardous Materials / Noise / Dust

  • Walking / Working Surfaces
  • Housekeeping / Storage
  • Lighting
  • Temperature Extremes / UVR Exposure
  • Liquid Transfer / Uncontrolled Discharge
  • Hazardous Materials / Noise / Dust

• PPE

  Select Basic PPE Task Specific PPE

  • Basic PPE
  • Task Specific PPE

• What do you think of the Fatigue Management?

  Safe

  At Risk

• Can you attach a sample copy of the training record for every 10th Interaction conducted?

  Media

Positive Feedback Notes

• What do you like most about the safety behaviors in your working environment?

At-Risk Behaviour Notes

• List33 at-risk behaviour observed.

• Was the employee AWARE of the at-risk behaviour?

  Select Yes No

  • Yes
  • No

• Does the employee AGREE that it is/was at-risk?

  Select Yes No

  • Yes
  • No

• List 3 employee’s REASON behind working at-risk?

• List 3 agreed suggestion for a SOLUTION?

FOR OFFICIAL USE ONLY.

• Quality Score:

• Responsible Person 1 (please include due date):

• Immediate Action:

• Completed?

  Yes

  No

  N/A

• Corrective Actions:

• Responsible Person 2 (please include due date):

• Immediate Action:

• Completed?

  Yes

  No

  N/A

• Corrective Actions:

• Responsible Person 3 (please include due date)

• Immediate Action:

• Completed?

  Yes

  No

  N/A

• Corrective Actions: