Safety Interaction Form

• Business Division

• Conducted on

  Date

• State

• Name of Assessor

• Site Name

• Activity/Task
  Address

• No. Of people observed

Procedures/Permits

• Pre Task hazard assessment completed (JSA/Take 5 etc.)

  Yes

  No

  N/A

• Follows safe work procedure for task (Working at heights, hot works)

  Yes

  No

  N/A

• Water conservation utilised (hoses off, leaks reported)

  Yes

  No

  N/A

• Hazardous materials & general waste (Proper waste disposal)

  Yes

  No

  N/A

• Management of change considered

  Yes

  No

  N/A

Ergonomics/Body Posture

• Eyes on task when operating tools

  Yes

  No

  N/A

• Hazardous energies controlled (thermal, mechanical, gravitational)

  Yes

  No

  N/A

• Avoids the line of fire - nip and pinch points

  Yes

  No

  N/A

• Avoids over extended, constraints & awkward postures

  Yes

  No

  N/A

• Avoids bending, twisting & repetitive mocements

  Yes

  No

  N/A

• Use three points of contact when climbing up/down stairs/ladders

  Yes

  No

  N/A

• Bends the knees and holds loads close to body when lifting/transferring

  Yes

  No

  N/A

Body Protection & PPE

• Hearing protection

  Yes

  No

  N/A

• Clothing - approved uniform (trousers, long sleeves, Hi-vis vest)

  Yes

  No

  N/A

• Gloves (good condition/appropriate)

  Yes

  No

  N/A

• Safety glasses & hats

  Yes

  No

  N/A

• Footwear (good condition/appropriate)

  Yes

  No

  N/A

Weather

• Protected from high temperatures-thermal, solar, dehydration, heat stress

  Yes

  No

  N/A

• Protected from rain/lightning (flooding)

  Yes

  No

  N/A

Tools and Equipment

• Correct tool/equipment for task used

  Yes

  No

  N/A

• Tools/equipment in good condition

  Yes

  No

  N/A

• Tools & Equipment are tested and tagged, cord inspections conducted

  Yes

  No

  N/A

Practices & Housekeeping

• Hazardous materials - use & storage

  Yes

  No

  N/A

• Removes & reports hazards & or implements controls

  Yes

  No

  N/A

• Appropriate use of barricades & signage

  Yes

  No

  N/A

• Obtains assistance for tasks as required (other person/mechanical aids

  Yes

  No

  N/A

• Communicates effectively regarding hazards in the work environment

  Yes

  No

  N/A

• Avoids rushing

  Yes

  No

  N/A

• Stable work surfaces & platforms (Area free of slips, trips & falls)

  Yes

  No

  N/A

Vehicles/Equipment/Driving

• Daily vehicle inspections completed

  Yes

  No

  N/A

• Drive to conditions of road

  Yes

  No

  N/A

• No use of mobile phone devices

  Yes

  No

  N/A

• Vehicle parked correctly (brakes, keys removed)

  Yes

  No

  N/A

• Operates equipment safely (safe interaction with people & equipment)

  Yes

  No

  N/A

Reactions of People

• Adjusting/fitting PPE

  Yes

  No

  N/A

• Changing position

  Yes

  No

  N/A

• Changing or swapping tools & equipment

  Yes

  No

  N/A

• Starting job

  Yes

  No

  N/A

At Risk Behaviour

• What is the at risk behaviour?

  Enter details

• What did the person say when behaviour discussed?

  Enter details

• Actions/Controls determined

  Enter details

• Positive Safety comments

  Enter details

• Observer comments (barriers that affect safety behaviour)

  Enter details