Title Page

  • Customer Name

  • Type of Work

  • Date

  • Conducted by

  • Location
  • Number of Persons Observed

  • Instruction: any item identified as "no" or at risk requires a documented action. All Reports must be kept as evidence. Email to yourself or your administrator and save in local teamroom or designated folder. File naming convention: include type, month/yr and your name/initials.

Readiness of People

  • Changing position

  • Stopping work

  • Rearranging task or job

  • Hiding or dodging

  • Changing tools

  • Applying Lockout Tagout

  • Adjusting PPE

Position of People

  • Striking against

  • Caught in-between

  • Heat or Cold Stress

  • Inhaling (chemical, dust, etc.)

  • Absorbing (chemical)

  • Electrical

  • Hazardous energy

  • Falling different level

  • Slip, trip, fall same level

  • Struck by

  • Vehicle or moving equipment

  • Other:

PPE personal protective equipment right for task and properly fitted, inspected and used

  • Head

  • Eyes

  • Face (face-shield used with safety glasses)

  • Ears (muffs, foam or custom ear plugs)

  • Respiratory system (seal, dust mask, half- or full face respirator, cartridge type -duration of use, all bands in place, clean shaven)

  • Hands and arms (glove type, size, cut-proof sleeves, no jewelry, sleeves)

  • Feet and legs (boot or shoe type, pants)

  • Other PPE:

Tools and/or Equipment

  • Right for the task or job

  • Used correctly

  • In safe good condition

  • Harness, SRL etc. Inspected & in good condition

  • Gloves right for task

  • Ladders, platforms, Barricades, railings in good condition & right for task

  • Warning (signs, alarms, etc.) in place & functional

  • Pre-job inspections completed & deviations corrected

  • Monitoring and/or measuring equipment in good condition & calibrated

  • Other:

Procedures

  • Has a complete, timely and accurate risk assessment has been completed for all their work tasks and updated when any changes occurred?

  • Does the risk assessment identify all hazards, risk rating and controls and are the controls fully implemented?

  • Has the supervisor been contacted to discuss how to effectively mitigate any residual risks (risk after implementation of control) with a medium or high rating, and have these controls been fully implemented?

  • Standard right for task or job

  • Standard readily available

  • Standard up-to-date

  • Permit to work in place, current, and complete

  • Fire watch in place

  • Gas testing completed documnted

  • Zero energy state verified

  • Emergency rescue in place

  • Other:

5S Orderliness & Tidyness

  • Standard in place & understood

  • Work area organized

  • Well-organized tools

  • Material storage right (hazmat 2-dary containment, shelving, etc.)

  • Stairs/platforms location (controlled access if in pathway)

  • Obstructions (adequate egress/ entrance)

Behaviour Observation Team Member(s)

  • Name and signature

  • Name and signature

  • Name and signature

  • Name and signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.