Safety Interaction

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Select date

  Date

• Observer Name:

• Employee's Dept.:

• Employee's Type:

• site:

• Location:

• Observation Condition:

• NORMAL

• SHUTDOWN

• BREAKDOWN

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

  Yes

  No

  N/A

• TASK DESCRIPTION:

• Can you tell me about your task:

• What are the main hazards/risks associated with this task?

• what controls do you have in place and do you think they are enough?

• What are the controls do you have in place and do you think they are enough?

• What are the current health and safety issues your department experiencing?

• How are these issues/concerns being addressed?

• On this job, do you feel there may be a need to deviate from standard procedure?

BEHAVIOR

• BODY POSITION

• Line of Fire

  Safe

  At Risk

  N/A

• quick notes:

• Eyes on Path

  Safe

  At Risk

  N/A

• quick notes:

• Ascending / Descending

  Safe

  At Risk

  N/A

• quick notes:

• Pinch Points/ Rotating Objects

  Safe

  At Risk

  N/A

• quick notes:

• MANUAL/ HANDLING ERGONOMICS

• Lifting/ Lowering

  Safe

  At Risk

  N/A

• quick notes:

• Twisting

  Safe

  At Risk

  N/A

• quick notes:

• Pushing / Pulling

  Safe

  At Risk

  N/A

• quick notes:

• Posture ? Overextended / Cramped

  Safe

  At Risk

  N/A

• quick notes:

• Response to Ergonomics Risk

  Safe

  At Risk

  N/A

• quick notes:

• TOOLS AND EQUIPMENT

• Tool/Equipment Selection

  Safe

  At Risk

  N/A

• quick notes:

• Tool/Equipment Condition

  Safe

  At Risk

  N/A

• quick notes:

• Guarding/Barricades/Delineation

  Safe

  At Risk

  N/A

• quick notes:

• PROCEDURES:

• Take 5/JHA/Project

  Safe

  At Risk

  N/A

• quick notes:

• Isolation / Tag- out

  Safe

  At Risk

  N/A

• quick notes:

• Communication of a Hazards

  Safe

  At Risk

  N/A

• quick notes:

• Permits

  Safe

  At Risk

  N/A

• quick notes:

• Light Vehicle Operations

  Safe

  At Risk

  N/A

• quick notes:

• Surface Mobile Equipment

  Safe

  At Risk

  N/A

• quick notes:

• Lifting Equipment

  Safe

  At Risk

  N/A

• quick notes:

• Explosives

  Safe

  At Risk

  N/A

• quick notes:

• Work at Height

  Safe

  At Risk

  N/A

• quick notes:

• Confined Space Entry

  Safe

  At Risk

  N/A

• quick notes:

• WORK ENVIRONMENT

• Walking / Working Surfaces

  Safe

  At Risk

  N/A

• quick notes:

• Housekeeping/ Storage

  Safe

  At Risk

  N/A

• quick notes:

• Lighting

  Safe

  At Risk

  N/A

• quick notes:

• Temperature Extremes / UVR Exposure

  Safe

  At Risk

  N/A

• quick notes:

• Liquid Transfer / Uncontrolled Discharge

  Safe

  At Risk

  N/A

• quick notes:

• Hazardous Materials/ Noise Dust

  Safe

  At Risk

  N/A

• quick notes:

• PPE

• Basic PPE

  Safe

  At Risk

  N/A

• quick notes:

• Task Specific PPE

  Safe

  At Risk

  N/A

• quick notes:

• Fatigue Management

  Safe

  At Risk

  N/A

• quick notes:

TRAINING COMPETENCY

• Check training and attach for every 10th interaction conducted.

  Safe

  At Risk

  N/A

• quick notes:

• POSITIVE FEEDBACK NOTES

AT- RISK BEHAVIOR NOTES

• What WAS the at-risk behavior observed?

• 2.

• 3.

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

  Yes

  No

  N/A

• 2.

  Yes

  No

  N/A

• 3.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 2.

  Yes

  No

  N/A

• 3.

  Yes

  No

  N/A

• What is the employee's REASON behind working at-risk?

• 2.

• 3.

• What is the agreed on suggestion for a SOLUTION?

• 2.

• 3.

• immediate Actions:

• Completed:

• Corrective Actions:

• Responsible Person:

• Due date: