Safety Interaction

• CGO Underground Project

• Conducted on

  Date

• Completed by

• Location

  Select

• Name work area?

  Select

• Name other work area?

• Contractor

  Select

• Name of other contractor?

  Select

• Contractor Supervisor Name

• Activity or Task Observed?

• Which workgroup?

• Number of workers involved in the task?

• Number of workers spoken to?

• Duration (Minutes):

• What was discussed:

Actions Observed

• Did you observe people using the correct PPE?

  Select Yes No NA

  • Yes
  • No
  • NA

• Check Items worn Correctly (Select multiple answers if they apply):

  Select

• Check Items not worn or used incorrectly (Select multiple answers if they apply):

  Select

• Did you observe people using tools and equipment safely?

  Select Yes No NA

  • Yes
  • No
  • NA

• Check all that apply (used correctly):

  Select

• Check all that apply (equipment or tools that were used incorrectly):

  Select

• Were the procedures for the job reviewed and considered safe (Select multiple answers if they apply)?

  Select Yes No NA

  • Yes
  • No
  • NA

• Select found safe... (Select multiple answers if they apply)?

  Select

• If no, the procedures in use were considered unsafe because... (Select multiple answers if they apply)??

  Select

• Was the work environment inspected and assessed safe?

  Select Yes No NA

  • Yes
  • No
  • NA

• If yes, the work area was considered safe because... (Select multiple answers if they apply)?

  Select

• If no, the work area was not safe because... (Select multiple answers if they apply)?

  Select

• Describe any safe acts observed:

• Describe any unsafe acts observed:

• Are corrective actions required, if yes list?

  Yes

  No

  NA

• Feedback:

• Name & Sign

  Sign

• Name & Sign

  Sign

• Name & Sign

  Sign

• Name & Sign

  Sign

• Name & Sign

  Sign