Safety Interaction Form

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

General

• Department:

• Area / Workgroup:

• Tasks Observed / Location:

• Total No. Of People Observed:

• CATEGORY (CAT). CLASS OF INTERACTION
  (PPE) Personal Protective Equipment. (SP) Safe Practice
  (PP) Positions of People. (SRV) Safe Rule Violation
  (ERG) Ergonomics. (UA). Unsafe Act
  (TE). Tools and Equipment. (UC). Unsafe Condition
  (PRO) Procedures
  (TID). Tidiness

Interactions and Actions Note: Team to record each interaction and action taken.

• Category:

• Class:

• Was a Positive Safety Interaction or Discussion conducted?

  Yes

  No

  N/A

• Category:

• Class:

• Was a Positive Safety Interaction or Discussion conducted?

  Yes

  No

  N/A

• Category:

• Class:

• Was a Positive Safety Interaction or Discussion conducted?

  Yes

  No

  N/A

• Category:

• Class:

• Was a Positive Safety Interaction or Discussion conducted?

  Yes

  No

  N/A

Areas for Improvement

• Category:

• Class:

• Was an Area for Improvement identified?

  Yes

  No

  N/A

• Has a person been assigned this action with a due date allocated?

  Yes

  No

  N/A

• Category:

• Class:

• Was an Area for Improvement identified?

  Yes

  No

  N/A

• Has a person been assigned this action with a due date allocated?

  Yes

  No

  N/A

Summary:

• Total No. of people working safely:

• Total No. of people working unsafely:

• Total UA's & SRV's:

• Unsafe Acts / hour:

• Safe Working Ratio:

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