Title Page

  • Conducted on

  • Prepared by

  • Project and work type

  • Location


  • Could the employees explain the task they were doing and what the critical safety risks were for the task? (Things that could cause injury/damage)

  • Critical safety risks

  • What control measures have been put in place that are keeping the employees safe while doing the task?

  • Are the controls keeping the employees safe and are they inline with the start card/SHEWMS/CRP's?

  • Comments

  • CRP's observed;


  • Environmental considerations

  • Other environmental considerations

  • Monthly SHEQ topic discussed?

  • Were any positive behaviours or conditions observed and discussed?

  • Were any areas of improvement observed and discussed?

  • Did you see any best practice or receive any great feedback that should be shared with others?

  • Rate your interaction today overall (1 being poor, 5 being excellent)

  • Rate your impression of the behavioural commitment to safety in the people you spoke with (1 being poor, 5 being excellent)

  • Rate how engaged the workers were with you during your interaction (1 being poor, 5 being excellent)

Close out

  • Were any actions identified and agreed upon during your interaction?

  • Action

  • Responsible person

  • Completion date

  • Additional actions

  • Actions
  • Action

  • Responsible person

  • Completion date

  • Site photos

  • Comments/Suggestions/Improvements/Innovations

  • Personnel interviewed

  • Additional personnel interviewed

  • Sign on
  • Add signature

  • Person completing

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.