Information
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Name of Employee
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SAP number
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Grade
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Shift
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Location
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Conducted on
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Reviewer
1. - REACTION OF PERSON
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1.1 - Adjusting Personal Protective Equipment
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1.2 - Changing Position
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1.3 - Rearranging Activity / Job
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1.4 - Stopping Activity / Job
2. - POSITION OF PERSON
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2.1 - Striking Against or Being Struck by Objects
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2.2 - Caught In, On or Between Objects
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2.3 - Falling
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2.4 - Contacting Temperature Extremes
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2.5 - Contacting Electric Current
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2.6 - Inhaling, Absorbing or Swallowing a Hazardous Substance
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2.7 - Repetitive Motions
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2.8 - Awkward Positions / Static Postures
3. - PERSONAL PROTECTIVE EQUIPMENT
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3.1 - Head
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3.2 - Eyes and Face
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3.3 - Ears
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3.4 - Respiratory System
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3.5 - Arms and Hands
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3.6 - Body
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3.7 - Legs and Feet
4. - TOOLS AND EQUIPMENT
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4.1 - Right for the Job
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4.2 - Used Correctly
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4.3 - In Safe Condition
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4.4 - Housekeeping
5. - PROCEDURES AND STANDARDS
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5.1 - Available
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5.2 - Adequate
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5.3 - Known
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5.4 - Understood
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5.5 - Followed
Sign Off
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Site Manager