Title Page

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Observed by

  • Location

EMPLOYEE INFORMATION

  • Employee's Department:

  • Employee Type:

  • Observation Condition

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

  • Task Description:

TASK DETAILS

  • Can you tell me about your task?

  • What are the hazards/risks identified with this task?

  • Are there enough safety controls in place?

  • If NO, what necessary safety controls are lacking/not available?

  • What controls do you have in place?

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

  • Are these issues addressed in a timely manner?

  • If NO, how do you think these issues should be addressed?

  • On this job, do you see a need to deviate from the standard procedure?

  • Please explain why there is a need to take a turn from the standard procedure.

BEHAVIOURS

BODY POSITION

  • Line of Fire

  • Eyes on Path

  • Eyes on Task

  • Ascending / Descending

  • Pinch Points / Rotating Objects

MANUAL HANDLING / ERGONOMICS

  • Lifting / Lowering

  • Twisting

  • Pushing / Pulling

  • Posture / Overextended / Cramped

  • Response to Ergonomic Risk

TOOLS AND EQUIPMENT

  • Tool/Equipment Selection

  • Tool/Equipment Condition

  • Tool/Equipment Use

  • Guarding / Barricades /Delineation

PROCEDURES

  • 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

  • Walking / Working Surfaces

  • Housekeeping / Storage

  • Lighting

  • Temperature Extremes / UVR Exposure

  • Liquid Transfer / Uncontrolled Discharge

  • Hazardous Materials / Noise / Dust

PPE

  • Basic PPE

  • Task Specific

  • Fatigue Management

TRAINING COMPETENCY

  • 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

  • List at-risk behaviour

  • Risk
  • What WAS the at-risk behaviour observed?

  • Is 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 SOLUTION suggestion was agreed upon?

ACTION PLANS

  • List Action Plan

  • Action Plan
  • Immediate Action

  • Completed

  • Corrective Action

  • Responsible Person

  • Due Date

COMPLETION

  • Completed by:

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. Any ratings or scores displayed in our Public Library have not been verified by SafetyCulture for accuracy. Users of our platform may provide a rating or score that is incorrect or misleading. You should independently determine whether the template is suitable for your circumstances. You can use our Public Library to search based on criteria such as industry and subject matter. Search results are based on their relevance to your search and other criteria. We may feature checklists based on subject matters we think may be of interest to our customers.