Safety Interaction Form

• Report Title

• Site

• Conducted on

  Date

• Prepared by

• Other Personnel involved

Section 1: Observation Report

• What was the task observed?

• Observation Category

  Select PPE Positions of people Ergonomics Tools & equipment Procedures Housekeeping

  • PPE
  • Positions of people
  • Ergonomics
  • Tools & equipment
  • Procedures
  • Housekeeping

• The observed behaviour was:

  Safe

  At Risk

  N/A

• The observed conditions were:

  Safe

  At Risk

  N/A

• What did the observer say? (e.g. questions asked, positive recognition given)

• What was the worker's response during the interaction?

Section 2: Improvement Actions

• Are follow up actions required?

  Yes - Complete Section 2

  No - Go to Section 3

• What follow up actions are required?

• Who will perform follow up actions?

• When is the follow up due?

  Date

• Copy of this report will be sent to person identified for follow up action

  Yes

  No

  N/A

• Date follow up action was completed

  Date

• Is a risk assessment required?

  Yes

  No

Section 3: Safety Interaction Self Assessment

• Did you have a discussion with people?

  Yes

  No

  N/A

• Did you give positive recognition? (e.g. Working safely, safe behaviour, safe conditions)

  Yes

  No

  N/A

• Did you per-plan the safety interaction?

  Yes

  No

  N/A

• Did you engage people in problem solving?

  Yes

  No

  N/A

• Did you assess the risks and hazards of the work the people were doing?

  Yes

  No

  N/A

• Have you discussed follow up actions with people listed as responsible and set agreed timing for closure?

  Yes

  No

  N/A