Information

  • Client / Site

  • Prepared by

  • Conducted on

  • Location
  • Document No.

  • Personnel

  • Activity/task

1.0 Documentation i.e. permits, mods, etc.

  • 1.1 Permit checked and signed off

  • 1.2 JHA (eg signed and completed)

  • 1.3 Take 5

  • 1.4 Follows written take 5 and JHA

2.0 Position of people/mobile equipment

  • 2.1 Avoid lines of fire (fingers, hands and body)

  • 2.2 Three points of contact when climbing or descending

  • 2.3 Avoid cramped or over extended posture

3.0 Ergonomics

  • 3.1 Bends knees when lifting

  • 3.2 Load close to the body

  • 3.3 Strong spine when lifting

  • 3.4 Turns with feet and not their back

  • 3.5 Lifts with their legs

  • 3.6 Mechanical aids/team lifting

4.0 Tools and equipment

  • 4.1 Correct for task

  • 4.2 Used correctly/safely

  • 4.3 Seat belts

  • 4.4 Per start inspection and completed log book

  • 4.5 Drives to road conditions

  • 4.6 Vehicle parked correctly (reversed/chocked)

5.0 Housekeeping/area conditions

  • 5.1 Work area tidy

  • 5.2 Barricades and signs

  • 5.3 Hazardous materials stored/handled/transported/used/disposed correctly

6.0 Personal protective equipment (PPE)

  • 6.1 Head

  • 6.2 Eye and face

  • 6.3 Hearing

  • 6.4 Respiratory

  • 6.5 Hand

  • 6.6 Sleeves rolled down and fastened

  • 6.7 Foot

  • 6.8 Fall arrest/restraint

  • 6.9 Sun/heat protection

At risk comments

  • What is that at risk behaviour? (number)

  • What did the person say when asked why?

  • Solution?

  • Resolved

  • What did the person say when asked why?

  • What is that at risk behaviour? (number)

  • Solution?

  • Resolved

  • What is that at risk behaviour? (number)

  • What did the person say when asked why?

  • Solution?

  • Resolved

Positive feedback comments

  • Comments

  • Add signature

Email to site safety department.

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.