SAFETY INTERACTION

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Observed by

• Location
  Address

EMPLOYEE INFORMATION

• Employee's Department:

• Employee Type:

• Observation Condition

  Normal

  Shutdown

  Breakdown

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

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

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

BEHAVIOURS

BODY POSITION

• Line of Fire

  Safe

  At Risk

  N/A

• Eyes on Path

  Safe

  At Risk

  N/A

• Eyes on Task

  Safe

  At Risk

  N/A

• Ascending / Descending

  Safe

  At Risk

  N/A

• Pinch Points / Rotating Objects

  Safe

  At Risk

  N/A

MANUAL HANDLING / ERGONOMICS

• Lifting / Lowering

  Safe

  At Risk

  N/A

• Twisting

  Safe

  At Risk

  N/A

• Pushing / Pulling

  Safe

  At Risk

  N/A

• Posture / Overextended / Cramped

  Safe

  At Risk

  N/A

• Response to Ergonomic Risk

  Safe

  At Risk

  N/A

TOOLS AND EQUIPMENT

• Tool/Equipment Selection

  Safe

  At Risk

  N/A

• Tool/Equipment Condition

  Safe

  At Risk

  N/A

• Tool/Equipment Use

  Safe

  At Risk

  N/A

• Guarding / Barricades /Delineation

  Safe

  At Risk

  N/A

PROCEDURES

• Take 5 / JHA / Prestart

  Safe

  At Risk

  N/A

• Isolation / Tag-out

  Safe

  At Risk

  N/A

• Communication of Hazards

  Safe

  At Risk

  N/A

• Permits

  Safe

  At Risk

  N/A

• Light Vehicle Operations

  Safe

  At Risk

  N/A

• Surface Mobile Equipment

  Safe

  At Risk

  N/A

• Lifting Equipment

  Safe

  At Risk

  N/A

• Explosives

  Safe

  At Risk

  N/A

• Work at Height

  Safe

  At Risk

  N/A

• Confined Space Entry

  Safe

  At Risk

  N/A

WORK ENVIRONMENT

• Walking / Working Surfaces

  Safe

  At Risk

  N/A

• Housekeeping / Storage

  Safe

  At Risk

  N/A

• Lighting

  Safe

  At Risk

  N/A

• Temperature Extremes / UVR Exposure

  Safe

  At Risk

  N/A

• Liquid Transfer / Uncontrolled Discharge

  Safe

  At Risk

  N/A

• Hazardous Materials / Noise / Dust

  Safe

  At Risk

  N/A

PPE

• Basic PPE

  Safe

  At Risk

  N/A

• Task Specific

  Safe

  At Risk

  N/A

• Fatigue Management

  Safe

  At Risk

  N/A

TRAINING COMPETENCY

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

  Safe

  At Risk

  N/A

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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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:

  Sign