Information
-
PREPARED BY:
-
Date
-
MANUFACTURING LINE
- Line 1
- Line 2
- Common System
-
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
-
Was a pre-job safety assessment properly completed for the job being observed?
-
Each individual observed working with a fall potential greater than six feet was using fall protective equipment or within standard handrails, bucket or basket, or other effective measures to prevent falls?
-
Is the safety harness and retractable lanyard properly selected, in good condition?
-
Was the fall protection equipment inspected prior to use?
-
Were anchorage points suitable to protect against the force of a fall?
-
Were elevated work platforms used of adequate size and capacity?
-
Were ladders nonconductive used and observed in good condition?
-
Were employees climbing ladders (fixed or portable) using three points of contact?
-
Is there a means of rescue for safely retrieving an employee who use fall restraint devices?
-
Does the list include all fall protection issues identified this observation?
SAFETY VISIT CARD - CHECKLIST
SAFETY VISIT CARD
-
CHECKLIST # 1 - MARK ALL BEHAVIOURS THAT APPLY
- Climbing or Standing on Equipment
- Climbing through Equipment (Awkward Position)
- Ascending/Descending (Stairs, Ladders, Platforms)
- Ergonomics (Position/Posture) (Pushing & Pulling)
- Eyes on Task
- Line of Fire (Being Struck By Something)
- Electrical Hazards (Following Safe Work Practices)
- Isolation (Installation of Lockout/Tagout / Try)
- Ergonomics (Lifting/Carrying)
- Line of Fire (Caught Between Something)
-
CHECKLIST # 2 - MARK ALL BEHAVIOURS THAT APPLY
- Stepping Over or Under Equipment (Awkward Position)
- Climbing Over Handrails
- Isolation (Securing or Bleeding Off Stored Energy)
- Personnel Protective Equipment (All Needed for Job)
- Vehicles & Driving (Securing Parked Vehicles)
- Vehicles & Driving (Maintaining an appropriate Speed)
- Proper Chemical Handling (Labeling, Storage, Use)
- Tools/Equipment (Correct For Job & Proper Use)
- Tools/Equipment (Good Condition or Properly Stored)
- Are Hazards Controlled (Eliminated/Barricading)
-
CHECKLIST # 3 - MARK ALL BEHAVIOURS THAT APPLY
- Reaching through Handrails
- Interaction with Vehicles
- Have Hazards/Risks been Communicated with Others
- Are there any Balance Traction Grip Issues
- Pre Job Safety Assessment Used
- Work at Heights (Protecting from Fall Hazards)
- Confined Spaces (Following Safe Work Practices)
- Work Environment (Hot, Cold, Wet, Etc.)
- Are Safe Work Practices being used?
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
