Thiess A & I LEADERSHIP SAFETY AND COMMUNICATION PERFORMANCE (Revision 11-6-2013)

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

ACTIVITY

JOB OBSERVATIONS (Safety Walks)

• Location (1)

  Safe

  At Risk

  N/A
• Add location
  Address

• Select date

  Date

• Location (2)

  Safe

  At Risk

  N/A
• Add location
  Address

• Select date

  Date

• Location (3)

  Safe

  At Risk

  N/A
• Add location
  Address

• Select date

  Date

• Location (4)

  Safe

  At Risk

  N/A
• Add location
  Address

• Select date

  Date

HSE COMMUNICATION (Attendance at Toolbox Meetings)

• Toolbox Meeting (1)

  Attended

  Not Attended
• Add location
  Address

• Select date

  Date

• Toolbox Meeting (2)

  Attended

  Not Attended
• Add location
  Address

• Select date

  Date

INCIDENT VIEW (Review of Monthly Incidents and Near Hits)

• Incidents reviewed ?

  Yes

  No

COMPLIANCE INSPECTIONS (Fixed Workplaces)

• Note workplace ?

  Inspection Undertaken

  Inspection Not Undertaken
• Add location
  Address

• Select date

  Date

CUSTOMER COMMUNICATIONS (Formal Client Contact)

• Customer (1)

  Acheived

  Not Acheived

• Select date

  Date

• Customer (2)

  Acheived

  Not Acheived

• Select date

  Date

• Customer (3)

  Acheived

  Not Acheived

• Select date

  Date

• Customer (4)

  Acheived

  Not Acheived

• Select date

  Date

• Add signature

  Sign

• Completed for the Month

  Date

Note* This an uncontrolled form and is for reference only.