Title Page
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Safety Conversation Guidance
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Observation Reference Number
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VPK site/dept
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Date and Time
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Observed by
Observations
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Action - Someone acts, use of tools, use of PPE, positioning, reactions to hazards.
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Condition - Environment, housekeeping, work area, condition of tools
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Action or condition observed?
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Categorize action
- Reactions of People
- Personal Protective Equipment (PPE)
- Position of People
- Tools Equipment and Machinery
- Procedures
- Orderliness/Housekeeping
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Specify (select from list)
- Adjusting Personal Protective Equipment
- Changing Position
- Rearranging Job
- Stopping Job
- Attaching Grounds
- Performing Lockouts
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Categorize
- All safe
- Head protection
- Eyes and Face protection
- Hearing protection
- Respiratory protection (RPE)
- Arms and Hand protection
- Trunk protection
- Legs and feet protection
- Hi Visibility Clothing
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Potential injury causation
- Striking Against or being Struck by Objects
- Caught In, On, or Between Objects
- Falls from height
- Contacting Temperature Extremes
- Contacting Electrical Current
- Inhaling, Absorbing or Swallowing a Hazardous Substance
- Repetitive Motions
- Awkward Positions/ Static Postures
- Horseplay
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Specify
- 618
- 924
- BXM
- Vega
- Vision 1
- Vision 2
- Baler
- Sheetline
- Pallet wrapper
- Corrugator Wet End
- Corrugator Dry End
- Other
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Specify Machine/Tool/Equipment
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Specify
- All Safe
- Adequate
- Known
- Understood
- Available
- Followed
- Unknown/Insufficient training.
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Observed MUST stop action immediately. Observed is putting themselves and others at undue risk. Report to nearest management. Observed must receive training for required task.
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Name of management/supervisor/OTL report to.
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Remedial actions (who will conduct training/retraining and when)
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Act Safe or Unsafe?
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Provide description of Safe Act.
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Was praise given for Safe Act?
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If applicable provide full name of person(s) observed
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Provide description of unsafe acts
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What immediate remedial actions were taken?
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Rate unsafe action risk
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Are long term actions are required?
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Why are long term actions not required? Risk sufficiently controlled?
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Provide detail of long term actions
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Do you need assistance to implement long term actions?
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Who do you need assistance from
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If 'other' selected provided name
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Categroise condition
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Specify
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Condition Safe or Unsafe?
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Why is condition deemed safe?
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Provide image(s) short video of safe condition
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Was praise given for safe condition?
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How was praise delivered?
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Who was praise given to? (Full names of employee(s) )
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Praise must be given as its a strong positive safety culture building tool. Can be simple as "Good job" and thumbs up. Or can be a direct conversation praising good safety behavior.
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Provide details on why condition is deemed unsafe?
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Provide image(s) or short video
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Risk Rating (risk posed by unsafe condition)
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Are any immediate actions required to rectify unsafe condition?
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Why is immediate action not possible?
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Are you able to implement immediate action?
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Do you require assistance?
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Who do you need assistance from?
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Provide details on immediate action
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Proof image(s) or short video of immediate action
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Are any long term actions required to further control risk?
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Describe long term controls required
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Do you require assistance to perform this control?
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Who do you need assistance from?
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Provide name of who you need assistance from
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Observer Signature
