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Stop Card Form
Stop Card Form
Stop Card Form
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Observer Details
Name
Company
Location
Date
Situation Corrected?
Yes
No
Site Details
Site
Accomodation
Yard
Office
Others
Acts At Risk
1.0 Use of PPE
Head
Eyes
Respiratory
Foot
Hearing
Hand
Fall Protection
Body
Arms / Legs
2.0 Body Position
Line of Fire
Ergonomic
Awkward position
Pinch points
Manual handling
3.0 People / Procedures
Lockout Tagout
Confined Space entry
Following barriers / signs
Permit to Work
Violation of VANTAGE Safety Rules
Third Party Behaviour
4.0 Tools and Equipment
Use of Guards
Tool / Equip use
Right tool for job
Use of Machinery
Mobile vehicles
Conditions At Risk
5.0 Workplace
Housekeeping
Barrier
Walking / work surface
Fall protection barriers
Work platforms
Noise
Health and Hygiene
Lighting
Equipment certification
Access / Egress
Condition of PPE
Emergency Response Equipment
Electrical
Lifting Equipment / Slings
Parts / Equipment condition
Tool / Equipment storage
6.0 Environment
Emissions / discharge
Spill-oil-chemical
Waste segregation
Energy use (waste)
Chemicals (storage / labels)
Temperature / Heat
Exposure to fumes
Description of Observation
Safe Act or Safe Condition Observed
At Risk (unsafe) Act Observed
At Risk (unsafe) Condition Observed
Corrective Action or recommendation
Corrective Action Status
Taken
Recommended
Improvement Suggestion
Submit
