Information

  • PREPARED BY:

  • Date

  • MANUFACTURING LINE

  • LOCATION / AREA

  • NAME OF EQUIPMENT

  • JOB DESCRIPTION (DESCRIBE SPECIFIC TASK)

  • NAME OF ADDITIONAL OBSERVERS

  • NUMBER OF IMERYS EMPLOYEES OBSERVED

  • NUMBER OF CONTRACTORS OBSERVED

  • Additional comments

RISK ANALYSIS

  • PICTURE OF THE SYSTEM / EQUIPMENT DURING THE INSPECTION

  • All moving machine parts observed (i.e. gears, sprockets, chains, drives, belts and take up pulleys, flywheels, couplings, shafts, fan blades or other moving parts) were provided with guards which met the requirements of MSHA and the Imerys S11 standards.

  • All individuals observed working near moving equipment had removed or secured loose clothing or jewelry which could cause entanglement.

  • Are guards maintained in good, secure condition and in place?

  • Adequate safety procedures have been taken for any guard which was removed during equipment service or maintenance.

  • All emergency stop devices appear to be in place and operational?

  • Does the list include all machine guarding issues identified this observation?

SAFETY VISIT CARD - CHECKLIST

SAFETY VISIT CARD

  • CHECKLIST # 1 - MARK ALL BEHAVIOURS THAT APPLY

  • CHECKLIST # 2 - MARK ALL BEHAVIOURS THAT APPLY

  • CHECKLIST # 3 - MARK ALL BEHAVIOURS THAT APPLY

HAZARDS & RISK ASSESMENT

ASSESMENT

  • Select the level of risk: Low, Medium, High

  • Is there a way to do the job/task "Better" and/or "Safer"?

  • Feedback Given:

  • Follow Up Action required ? (if any, submit action plan)

ENDING TIME

  • ENDING 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.