Information

  • Name of Employee

  • SAP number

  • Grade

  • Shift

  • Location
  • Conducted on

  • Reviewer

1. - REACTION OF PERSON

  • 1.1 - Adjusting Personal Protective Equipment

  • 1.2 - Changing Position

  • 1.3 - Rearranging Activity / Job

  • 1.4 - Stopping Activity / Job

2. - POSITION OF PERSON

  • 2.1 - Striking Against or Being Struck by Objects

  • 2.2 - Caught In, On or Between Objects

  • 2.3 - Falling

  • 2.4 - Contacting Temperature Extremes

  • 2.5 - Contacting Electric Current

  • 2.6 - Inhaling, Absorbing or Swallowing a Hazardous Substance

  • 2.7 - Repetitive Motions

  • 2.8 - Awkward Positions / Static Postures

3. - PERSONAL PROTECTIVE EQUIPMENT

  • 3.1 - Head

  • 3.2 - Eyes and Face

  • 3.3 - Ears

  • 3.4 - Respiratory System

  • 3.5 - Arms and Hands

  • 3.6 - Body

  • 3.7 - Legs and Feet

4. - TOOLS AND EQUIPMENT

  • 4.1 - Right for the Job

  • 4.2 - Used Correctly

  • 4.3 - In Safe Condition

  • 4.4 - Housekeeping

5. - PROCEDURES AND STANDARDS

  • 5.1 - Available

  • 5.2 - Adequate

  • 5.3 - Known

  • 5.4 - Understood

  • 5.5 - Followed

Sign Off

  • Site Manager

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.