1STA Date: 1STA Time: 1STA Supervisor :

Job Site: Company Audited:

1Task Description: STA Auditor : Audit Date: Audit Time:

Audit Element Possible Points Comments

Points Earned
1. Is STA top section completed correctly? Yes No
STA Date Contractor Name
0/5
STA Time STA Supervisor/ In Charge Sign
Task Location Task Description
2. Does work involve Lockout Tag out Yes No
or Confined Space Entry (CSE)?
If so, is LOTO and/or CSE Permit in place? Yes No 0/5

Is Permit completed correctly? Yes No

3. Have all the required JSA/Procedures/

Yes No 0/5
T H I N K I N G IT T H R O U G H

Permits /Tags/Signs/ been identified?

4. Is Emergency preparedness /resources

Yes No
available at site?
Safety Shower/ Eyewash Rescue Plan (If Applicable) 0/5
Fire Extinguisher Assembly Areas Defined
J3 Program Emergency Contact Numbers Display
5. Have Training/Certification/Validation
Requirements, PPE and Equipment Needs Yes No 0/5
been thought out and clearly identified?
6. Have all Possible HSE Concerns clearly
Yes No 0/5
identified?
7. Does the Sequence of Job Steps
Yes No 0/5
actually match the work being done?
8. Does the Sequence of Job Steps
include the steps, equipment and tools Yes No 0/5
associated with each step?
9. Are the specific hazards clearly
Yes No 0/5
identified for each of the job steps?
10. Are Actions to be Taken clearly defined
Yes No 0/5
for all identified hazards?
11. Have pertinent Specific Hazards and Safe
Yes No 0/5
Work Practices properly communicated?
12. Reviewed/signed during routine inspection
Yes No 0/5
by Management? Field/Lead Engineer/HSE?
13. Are all workers listed and the proper
Yes No 0/5
Supervisor signed on/off the STA?
14. Are workers following the Sequence of
Yes No 0 / 10
Job Steps as identified on the STA?
EXECUTION

15. Have workers performed the Actions to

Yes No 0 / 10
be Taken as identified on the STA?
16. Do workers demonstrate awareness
Yes No 0 / 10
and compliance with the STA?
17. Post STA Section completed? (If audited after
Yes No 0/5
completion of task)
Corrective Actions Suggested: 95 - 100 % = Excellent
90 - 94% = Very Good
Total 100 85 - 89 % = Good
70 - 84 % = Improvement Required
85% = Minimum acceptable score

Note: To be used to audit 1Single STA or Multiple STA implemented at site for various activities.

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