• Worker Name (first & last)

  • Worker Occupation

  • Date of Assessment

  • New / Returning Worker

  • Monthly Assessment

  • Worker Observation

  • Location
  • Worker assessment to be completed once per worker per month. This checklist should also be used to assess a new hire or a returning worker that has been away from the job for more than 6 weeks. Check appropriate boxes if "unsafe" or mark N/A. If "unsafe", provide corrective action comments for worker.

Company Policies & Procedures

  • If "Unsafe" add comments and/or photographs. If all items safe, select "Safe" from pull down arrow to the right.

Emergency Response Plan (ERP)

  • Can locate ERP

  • Knows personal location on map

  • Can identify "Safe" areas

  • Can identify FA attendant(s)

  • Has appropriate FA equipment

Safe Work Procedures for task

  • Can identify worksite hazards

  • Is alert and focused on job

  • Demonstrates safe use of tools & equipment

  • Demonstrates Lock-out procedures

  • Uses 3 point mount / dismount

  • Has pre-operational checklist(s)

  • Has required licence / certificate(s)

  • Demonstrates proper use of seat belt

Before "clear to approach" signal given

  • Stops work & makes eye contact

  • Stops all moving parts or tools

  • Lowers blad / boom / head / saw

  • Gives "clear to approach" signal

Personal Protective Equipment (PPE)

  • Hard hat of contrasting colour

  • Uses required hearing protection

  • Uses appropriate eye / face protection

  • Wears high visibility / protective clothing

  • Wears appropriate footwear for job


  • Comment

Sign Off

  • New worker is competent to perform assigned duties under normal supervision

  • Signature of Supervisor / Trainer

  • Signature of Employee/ Contractor

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.