Information
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Document No.
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Audit Title
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Location/Project Name
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Conducted on
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Observer Name
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Location
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Personnel Observed
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Task Observed
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Description of Task Observed and Background Information
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Positive Comments
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At Risk Behaviors Observed
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Conclusions
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Feedback Session Conducted By:
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At Risk Observation #1
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Solution(s) to Prevent Potential Incident from Occuring
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Responsible Person
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Agreed Due Date
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At-Risk Observations/Root Cause Analysis #1
- Lack of skill or knowledge
- Correct way takes more time or requires more effort
- Shortcutting standard procedures is rewarded or appreciated
- In the past, did not follow procedures or acceptable practices and no incident occured
- Lack of or inadequate operational procedures or work standards
- Inadequate communication of expectations or work standards
- Inadequate tools or equipment
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At Risk Observation #2
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Solution(s) to Prevent Potential Incident from Occuring
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Responsible Person
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Agreed Due Date
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At-Risk Observations/Root Cause Analysis #2
- Lack of skill or knowledge
- Correct way takes more time or requires more effort
- Shortcutting standard procedures is rewarded or appreciated
- In the past, did not follow procedures or acceptable practices and no incident occured
- Lack of or inadequate operational procedures or work standards
- Inadequate communication of expectations or work standards
- Inadequate tools or equipment
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At Risk Observation #3
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Solution(s) to Prevent Potential Incident from Occuring
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Responsible Person
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Agreed Due Date
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At-Risk Observations/Root Cause Analysis #3
- Lack of skill or knowledge
- Correct way takes more time or requires more effort
- Shortcutting standard procedures is rewarded or appreciated
- In the past, did not follow procedures or acceptable practices and no incident occured
- Lack of or inadequate operational procedures or work standards
- Inadequate communication of expectations or work standards
- Inadequate tools or equipment
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At Risk Observation #4
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Solution(s) to Prevent Potential Incident from Occuring
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Responsible Person
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Agreed Due Date
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At-Risk Observations/Root Cause Analysis #4
- Lack of skill or knowledge
- Correct way takes more time or requires more effort
- Shortcutting standard procedures is rewarded or appreciated
- In the past, did not follow procedures or acceptable practices and no incident occured
- Lack of or inadequate operational procedures or work standards
- Inadequate communication of expectations or work standards
- Inadequate tools or equipment
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Supervisor:
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Approved by (Practice Safety Leader):
