Title Page
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Document No.
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Company
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Task
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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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Safety Conversation - Observing and engaging with the workforce
Actions of people
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Actions of people
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Adjusting PPE
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Changing position
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Rearranging job
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Stopping job
Personal protective equipment
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Head
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Eyes
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Ears
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Respitory system
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Arms hands
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Trunk
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Legs feet
Equipment use
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Wrong for job
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Used incorrectly
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In an unsafe condtion
Body position and use
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Stuck by object
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Striking against object
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Caught in on or between objects
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Overexertion
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Awkward positions
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Falling tripping
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Contacting electrical current
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Cantacting temperature extremes
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Inhaling hazardous substances
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Swallowing hazardous substances
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Absorbing hazardous substances
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Repetitive motion
Adherance to procedures
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SWMS requirements
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Work procedure or SWMS inadequate
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Work procedure or SWMS not followed
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Work procedure misunderstodd
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Housekeeping inadequate
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Housekeeping standards not known or misunderstood
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Poor facility condition / working condition
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Utake5 not conducted
Feedback
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Feedback
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Results of observation
- Safety Issue
- Improvement
- Action
- Positive Observation
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Notes
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Please sign