Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
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Property
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Department
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Observation Date
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Observer
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Task
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Employee
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Select One
- New employee < 90 days
- Returning from injury
- In job > 5 years
- Discomfort
- Disregard safe practice
- Other
In NO is checked, you must select a reason for the At Risk Behavior or Condition and include corrective action in the comments section at the end of this audit. ST: Safety Training no provided within last 12 months or documented; SP: Safe Practice not followed; JD: Job Design
Behavioral Risk Factors
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Surface free of slippery contaminates (water, grease, oil, etc.) with adequate maintenance
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Select one
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Use wet floor signs/cones/ Surface is mopped/swept until cleaned. Be aware of the likelihood of wet surfaces. Wear slip-resistant footwear/soles that are in good condition.
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Details of Observation
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Wears proper footwear for work area
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Select one
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Wear slip resistant shoes with soles in good condition and not worn smooth.
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Details of Observation
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Moves at a reasonable pace, not moving too quickly/aggressively, rushing to complete task
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Select one
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Walk, do not run. Request help to reduce pace of work being performed.
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Details of Observation
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Uses step ladder or other tool rather than climbing on equipment/chairs/furniture/racks
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Select one
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Use proper size ladder, stool, extension / telescoping handle. Ask for assistance.
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Details of Observation
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Step ladder, step stool in reasonable condition
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Select one
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Inspect condition of equipment. Replace defective equipment. Notify supervisor to remove from service.
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Details of Observation
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Does not carry / handle objects while climbing ladders, stools, etc.
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Select one
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Request that another employee assist after ascending and before descending ladder / stool.
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Details of Observation
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Removes foreign object(s) on floor, stairs, or ramps
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Select one
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Ensure walking working surface is clear of debris and an adequate path of travel is provided.
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Details of Observation
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Operates within authority and job description
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Select one
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Refuses to attempt task that s/he is not trained/qualified to complete safely. Supervisor notified. Employee replaced with on who has proper training.
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Details of Observation
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Follows written / oral procedure / instruction
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Select one
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Retraining provided and documented.
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Details of Observations
Conditions / Environmental Risk Factors
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Working in area with adequate lighting, glare, color contrasts, etc.
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Select one
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Ability to see feet, lighting works and illumination strength is adequate for tasks performed.
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Details of Observations
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Stairs - travels fewer than 2-3 stairs, proper hand / guard rails, stair treads
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Select one
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Limit use of stairs - use elevator, use hand rail; adjust loads, ask for assistance.
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Details of Observations
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Surface composition (floor material) is appropriate: wood, tile, carpet, concrete, etc.
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Select one
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Non-slip footwear, mats, drains, etc. Ensure good housekeeping is maintained.
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Details of Observations
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Limited foreign substance potential - water, soap, grease, etc.
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Select one
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Clean as you go, wet floor signs / cones used to mark area until cleaned.
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Details of Observations
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Surface condition is reasonable - no cracks, chips, tears, frays
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Select one
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Report to supervisor. Notify Facilities - complete work order.
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Details of Observations
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No surface composition (floor material) changes: carpet to tile, wood to tile, etc.
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Select one
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Visible transitions, contrasting colors, markings, etc. Be aware of surfaces changes in specific work areas.
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Details of Observations
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Path is free of elevation or level changes: stairs, ramps, curbs, etc.
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Select one
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Visible transitions, contrasting colors, marking, etc. Be aware of surfaces changes in specific work areas.
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Details of Observations
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Walking path is free of obstructions
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Select one
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Remove obstructions from path before proceeding to walk through area.
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Details of Observations
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Comments regarding observations - positive reinforcement or corrective action for at-risk behaviors and conditions - ST, SP, JD.
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Date of coaching
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Employee initials
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Supervisor / Manager initials
