Employee Audit form

Worker Name & ID Worker Position Direct Supervisor Team member names & ID

HSE Coordinator
Date Location
Performing Audit

Stop work- Unsatisfactory – Satisfactory –

Color Exceeds
Requirement not immediate action no action
Code Expectations
met required required

1.0 Daily ToolBox N/A

1.1 Has employee taken part in Toolbox meeting and signed on
2.0 Documentation N/A
2.1 Employee has completed FLHA
2.2 Does employee hold proper competencies
2.3 Does Employee have CSTS-2020
2.4 Does Employee Have WHIMIS
2.5 Employee has completed equipment inspection
2.6 Employee has completed site orientation
2.7 Safe work permit (if required)
2.8 Ground disturbance permit (if required)
2.9 Worker has appropriate ground disturbance certificate
3.0 FLHA Inspection N/A
3.1 FLHA accurately captures all workers involved in the task, location,
date/time.
3.2 Supervisor responsible is identified.
3.3 Supervisor has signed off on FLHA.
3.4
Emergency contact details included.
3.5 All relevant & specific hazards identified, and controls put in place.
3.6 FLHA identifies the scope of work, steps involved in the task?
3.7 If the job scope has changed or new hazards have been introduced, teams
have stopped work to discuss new conditions, update FLHA and signed on?
3.8 Workers / crew can verbally outline and fully understand the task at hand,
hazards associated, and control measures put in place.
4.0 Equipment Inspection N/A
4.1 Equipment inspection has been filled out
Equipment is in good working order (HSE Coordinator to perform inspection
4.2
to verify operators inspection)
4.3 Machine maintenance is up to date
4.4 Machine house keeping is satisfactory.
5.0 Personal Protection Equipment N/A
5.1
Worker has all appropriate PPE required for site and task being performed.
5.2 PPE is in good condition.
5.3
Boots are appropriate Height (6”)
5.4 All PPE CSA approved
6.0 Scope of Work N/A
6.1 Worker fully understand the task they are performing?
6.2 Worker has appropriate training for the task being performed.
6.3 Worker is Fit For Duty.
6.4 Worker can verbally identify hazards and controls for task being performed?
6.5 If worker is new, someone is designated as the trainer.
7.0 Tools N/A
7.1 Tools being use are in good working condition
7.2 Worker has been trained for the tools being used
8.0 Working at Height Platforms N/A
8.1 Worker has Mobile Elevating Work Platform Certification
8.2 Harness and fall arrest lanyard in good working condition and not expired
8.3 Worker is hooked up properly
10.0 Lifting Operations N/A
10.1 Lift plan is in place
10.2 Everyone involved in the lift has signed onto the FLHA
10.3 All appropriate parties have been notified
10.4 Safe work permit has been issued
10.5 Lift calculation is completed (only for crane lifts)
10.6 Lift is >75% capacity
11.0 ToolBox
11.1 Tool Box is filled out properly
11.2 Task being performed is noted
11.3 Task plan is descriptive and understandable
11.4 Safety topic is noted
12.0 Fit For Duty N/A
12.1 Worker is Fit For Duty
12.2 Worker understands the meaning of fit for duty
13.0 Incident reporting and Hazard ID reporting N/A
13.1 Worker can describe the steps in the event of an incident
13.2 Worker understands all incidents / near misses / injuries must be reported
13.3 Worker understands to report any unsafe work / condition
13.4 Worker Understands Hazard ID reporting
14.0 First Aid / Fire extinguisher / Muster location N/A
14.1 First Aid locations known
14.2 Fire extinguisher locations are known
14.3 Muster location known
15.0 Emergency Procedure N/A
15.1 Worker can verbally describe what to do in the event of a muster
15.2 Worker knows all exit points incase muster points aren’t available
16.0 Environmental Reporting N/A
16.1 Worker understand to report all spills and leaks
16.2 Spill Kit locations are known
16.3 Worker understands how to use a spill kit

A copy of this form is to be sent to the Health & Safety Team on completion of the inspection.
A copy is to be kept by the Direct Supervisor. Any outstanding issues must be addressed and
updated form sent to H&S Team within the time frame agreed upon.
 Section Issue identified Corrective Action(s) Action Agreed Date Completed Action
Number Owner(s) for (Date) owner
Completion Initial

OTHER COMMENTS

HSE Name:________________________ Employee Name & ID:____________________ Manager Name:_______________________

HSE Signature:_____________________ Employee Signature:______________________ Manager Signature:____________________