Title Page

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Safety Interaction

  • Observer Name:

  • Select date

  • Employee's Department:

  • Employee Type:

  • Site:

  • Location:

  • Observation Condition:

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

  • Task Description:

Questions for the Employee

  • 1. Can you tell me about your task?

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

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

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

  • 5. How are these issues / concerns being addressed?

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


  • Line of Fire

  • Eyes on path

  • Eyes on Task

  • Ascending / Descending

  • Pinch Points / Rotating Objects


  • Lifting / Lowering

  • Twisting

  • Pushing / Pulling

  • Posture / Overextended / Cramped

  • Response to Ergonomic Risk


  • Tool/Equipment Selection

  • Tool/Equipment Condition

  • Tool/Equipment Use

  • Guarding / Barricades / Delineation


  • 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


  • Walking / Working Surfaces

  • Housekeeping / Storage

  • Lighting

  • Temperature Extremes / UVR Exposure

  • Liquid Transfer / Uncontrolled Discharge

  • Hazardous Materials / Noise / Dust

PPE (Personal Protective Equipment)

  • Basic PPE

  • Task Specific PPE


  • Fatigue Management

  • Check training record and attach for every 10th Interaction conducted

Positive Feedback Notes

    What were the safe behaviours you observed and what did you like about them?

At-Risk Behaviour Notes

    What WAS the at-risk behaviour observed?
  • Was the employee AWARE of the at-risk behaviour?

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

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

  • What is an agreed on suggestion for a SOLUTION?

Action Notes

    Immediate Actions
  • Completed

  • Corrective Actions

  • Responsible Person

  • Due Date


  • Quality Score:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.