Safety interaction form checklist

Template Information

Records interactions about safety

Category: general

Template Questions

  • What was the task observed?
  • Observation Category
  • Section 1: Observation Report
  • What did the observer say? (e.g. questions asked, positive recognition given)
  • What was the worker's response during the interaction?
  • Section 2: Improvement Actions
  • What follow up actions are required?
  • Who will perform follow up actions?
  • When is the follow up due? Date
  • Date follow up action was completed Date
  • Section 3: Safety Interaction Self Assessment