Title Page

  • Document No.

  • Company

  • Task

  • Conducted on

  • Prepared by

  • Location
  • Personnel

  • Safety Conversation - Observing and engaging with the workforce

Actions of people

  • Actions of people

  • Adjusting PPE

  • Changing position

  • Rearranging job

  • Stopping job

Personal protective equipment

  • Head

  • Eyes

  • Ears

  • Respitory system

  • Arms hands

  • Trunk

  • Legs feet

Equipment use

  • Wrong for job

  • Used incorrectly

  • In an unsafe condtion

Body position and use

  • Stuck by object

  • Striking against object

  • Caught in on or between objects

  • Overexertion

  • Awkward positions

  • Falling tripping

  • Contacting electrical current

  • Cantacting temperature extremes

  • Inhaling hazardous substances

  • Swallowing hazardous substances

  • Absorbing hazardous substances

  • Repetitive motion

Adherance to procedures

  • SWMS requirements

  • Work procedure or SWMS inadequate

  • Work procedure or SWMS not followed

  • Work procedure misunderstodd

  • Housekeeping inadequate

  • Housekeeping standards not known or misunderstood

  • Poor facility condition / working condition

  • Utake5 not conducted

Feedback

  • Feedback

  • Results of observation

  • Notes

  • Please sign

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