• Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

  • Select date

  • Facility name:

  • Facility current operation:


  • Name:

  • Picture of person as you walk up to them

  • Title:

  • Number of years on the job? SSE? Name of Mentor?

  • Job at hand when walking up to person

  • Location of interview on facility

Current PPE

  • Hardhat, steel toes, safety glasses

  • Ear plugs

  • Gloves

  • Face shield

  • Apron

  • Other PPE

Job task when you walked up to personnel (Section 3. JSA)

  • Did s/he stop the job and make it safe to talk to you? (Picture)

  • Is there a JSA Onsite for the job?

  • Is the JSA complete with hazard mitigation, does it match the job at hand?

  • Have all parties involved with the job signed the JSA?

  • Describe "Stop the Job"

Section 1. General Provisions

  • Describe SEMS?

  • Where are the SEMS documents kept on the facility?

  • Who enforces SEMS?

Section 2. Safety and Environmental Information

  • What is the color code system for the Piping on your facility?

  • Describe the waste handling of your facility

  • Tell me about your facility's safety oberservation program

Section 3. Hazard Analysis

  • Tell me about some of the safety signs that are posted around your facility

  • Describe the information found on a MSDS sheet and where are they located

Section 4. Management of Change

  • Describe an MOC?

  • Give me an example of when you would use a Management of Change.

Section 5. Operating Procedures

  • Tell me about an ESD

  • Tell me about a permit to work.

  • Where are you written work procedures stored

Section 6. Safe Work Practices

  • Are you currently operating under a bridging document?

  • Name an item that is on your bridging document.

  • What would you do if you find yourself with two conflicting safety rules?

  • How are your risks labeled around the platforms?

Section 7. Training

  • Describe a lock out / tag out

  • Tell about rigger training and when was the last time you attended?

  • What safe work practices trainings have you attended?

  • Are you on the fire team? When was your last training session? What information was covered?

  • Are you first aid trained, can you use an AED?

Section 8. Mechanical Integrity

  • Tell me about the maintenance of the facility's equipment

Section 9. Per-Startup Review

  • What information is available if you come across a lock out / tag out?

  • Tell me about the pre start up checks before you start a piece of equipment?

Section 10. Emergency Response and Control

  • Describe the facility's alarms

  • Do you have any roles during emergencies? What are they?

  • Describe:

  • Where is your muster point?

  • How do you show accountability at the muster point?

  • When and what was the last drill you were involved in?

  • How is a man overboard handled?

Section 11. Investigate of Incidents

  • After an incident who does the investigation for this facility?

  • Describe root cause analysis?

Section 12. Audits

  • What is the importance of reviewing your safety plan at regular intervals?

  • Name some typical inspections and audits that happen on your facility.

Section 13. Records and Documents

  • What is the typical length of time you must keep a document onboard your facility? (6years)

  • After the job is complete where is the JSA stored?

Complete the interview

  • Hand the interviewee a business card, inform them of our open door policy, and thank them for their time.

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.