Title Page
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Leader's Name
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Date
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Area of Responsibility
Safety Check
PPE (Personal Protective Equipment)
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PPE
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Did you observe anyone NOT wearing their PPE?
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Name of person? What PPE were they NOT wearing? What is their reason for not wearing it? How did you resolve the issue?
Housekeeping
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Housekeeping
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Did you observe any housekeeping issues?
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What is the housekeeping issue? Please include photo(s) if possible. How did you resolve the issue?
Hazards (Unsafe Conditions & Unsafe Behaviours)
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Hazards - Unsafe Conditions
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Did you observe any unsafe conditions that could cause injury? (e.g. broken equipment/machinery, defective tool, etc.)
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What is the unsafe physical condition? Please include photo(s) if possible. How did you resolve the issue?
Hazards - Unsafe Behaviours
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Did you observe any unsafe behaviours that could cause injury? (e.g. throwing things, speeding, poor ergonomics, etc.)
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Name of person? What were they doing? How did you resolve the issue?
Safety Concerns
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Safety Concerns
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Did anyone express any health & safety concerns to you?
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What is the health and safety concern? How did you resolve the issue?
Incident Reports
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Incidents
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Did anyone in your area of responsibility have a near miss or injury?
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Name of person? What happened? What actions were taken to help prevent re-occurrence? Were the required incident reports filled out and signed? Was the incident documented in intelex within 2 hours?
Exemplary Behaviours
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Exemplary Behaviours
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Did you observe any exemplary behaviours that contribute to health & safety in the workplace?
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Name of person? What did they do?
Safety Ideas
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Safety Ideas
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Did anyone express any ideas for improving safety in the workplace?
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Name of person? What is their idea? Should it be implemented? Why or why not? If yes, how could it be implemented?
Safety Summary & Sign-Off
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What went well today in your area of responsibility? What could be improved? Any reminders/communications to the team?
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Leader's Signature
