Information
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Document No.
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Work area inspected
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Conducted on
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Prepared by
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Location
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Personnel
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Select date
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Activity/task
1.0 Documentation i.e. permits, mods, etc.
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1.1 Permit checked and signed off
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1.2 JHA (eg signed and completed)
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1.3 Take 5
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1.4 Follows written take 5 and JHA
2.0 Standards and procedures
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2.1 Sources of energy controlled
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2.2 Attached lock and tag to isolation points
3.0 Position of people/mobile equipment
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3.1 Avoid lines of fire (fingers, hands and body)
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3.2 Three points of contact when climbing or descending
4.0 Ergonomics
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4.1 Bends knees when lifting
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4.2 Load close to the body
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4.6 Mechanical aids/team lifting
5.0 Tools and equipment
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5.1 Correct for task
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5.2 Used correctly/safely
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5.3 Vehicle parked correctly (reversed)
6.0 Housekeeping/area conditions
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6.1 Work area tidy
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6.2 Barricades and signs
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6.3 Bunds in place to suitable height
7.0 Personal protective equipment (PPE)
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7.1 Head
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7.2 Eye and face
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7.3 Hearing
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7.4 Respiratory
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7.5 Hand
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7.6 Sleeves rolled down and fastened
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7.7 Foot
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7.8 Fall arrest/restraint
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7.9 Sun/heat protection
At risk comments
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What is that at risk behaviour? (number)
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What did the person say when asked why?
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Solution?
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Resolved
Positive feedback comments
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Comments
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