Stop Audit PLA

• Audit Title

• Conducted on

  Date

• Prepared by

Reaction of People

• Adjusting PPE

  Safe

  At Risk

  N/A

• Changing Position

  Safe

  At Risk

  N/A

• Rearranging Job

  Safe

  At Risk

  N/A

• Stopping Job

  Safe

  At Risk

  N/A

• Attaching Grounds

  Safe

  At Risk

  N/A

• Performing Locks

  Safe

  At Risk

  N/A

• Comments

Personal Protective Equipment and Quality Protective Equipment

• Head

  Safe

  At Risk

  N/A

• Eyes and face

  Safe

  At Risk

  N/A

• Ear Plugs

  Safe

  At Risk

  N/A

• Respiratory System

  Safe

  At Risk

  N/A

• Arms and hands

  Safe

  At Risk

  N/A

• Trunk

  Yes

  No

  N/A

• Legs and feet

  Yes

  No

  N/A

• Comments

Positions of People

• Striking against

  Safe

  At Risk

  N/A

• Struck by Objects

  Safe

  At Risk

  N/A

• Caught in, on, or between objects

  Safe

  At Risk

  N/A

• Falling

  Safe

  At Risk

  N/A

• Contacting Extreme Temperatures

  Safe

  At Risk

  N/A

• Contacting electrical current

  Safe

  At Risk

  N/A

• Inhaling, absorbing, or swallowing a hazardous substance

  Safe

  At Risk

  N/A

• Overexertion

  Safe

  At Risk

  N/A

• Repetitive Motions

  Safe

  At Risk

  N/A

• Awkward positions, static postures

  Safe

  At Risk

  N/A

• Comments

Tools

• Wrong for the job

  Safe

  At Risk

  N/A

• Used Incorrectly

  Safe

  At Risk

  N/A

• In Unsafe condition

  Safe

  At Risk

  N/A

• Comments

Procedures

• Procedures Inadequate for the job

  Safe

  At Risk

  N/A

• Procedures Not Known and Understood by all concerned

  Safe

  At Risk

  N/A

• Procedures known and understood but Not Followed

  Safe

  At Risk

  N/A

• Orderliness Standards Inadequate for the job

  Safe

  At Risk

  N/A

• Orderliness Standards Not Known and Understood by all concerned

  Safe

  At Risk

  N/A

• Orderliness Standards known and understood but Not Followed

  Safe

  At Risk

  N/A

• Comments

Observation Report

Safe Acts

• What safe acts were observed?

• What actions were taken to encourage safe performance

Unsafe Acts

• What unsafe acts were observed?

• What corrective action was taken?

• What action was taken to prevent further occurance?