Has the employee been observed by someone else this month?
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.
Line of Fire
Eyes on Path
Eyes on Task
Ascending / Descending
Pinch Points / Rotating Objects
Lifting / Lowering
Pushing / Pulling
Posture / Overextended / Cramped
Response to Ergonomic Risk
Guarding / Barricades /Delineation
Take 5 / JHA / Prestart
Isolation / Tag-out
Communication of Hazards
Light Vehicle Operations
Surface Mobile Equipment
Work at Height
Confined Space Entry
Walking / Working Surfaces
Housekeeping / Storage
Temperature Extremes / UVR Exposure
Liquid Transfer / Uncontrolled Discharge
Hazardous Materials / Noise / Dust
Check training record and attach for every 10th interaction conducted
What were the safe behaviours you observed and what did you like about them?
List at-risk behaviour
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?
List Action Plan