• Observers name

  • Employee observed

  • Date and time of observation

  • Select Department where observation occurred


  • Describe positive behaviors observed

  • Photos if helpful

  • Describe conversation with associate about positive behaviors

  • Describe each at risk behavior

  • At Risk Behavior
  • Describe behavior observed

  • Photos showing risks

  • Describe preventative action discussed with employee

  • Photo showing preventative actions/behaviors


  • Observer name and signature

  • Observer 2 name and signature

  • Employee name and signature

Safety Committee Review

  • Comments - Recommendations

  • Photos

  • Drawings

  • Review Date

  • General Manager 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. Any ratings or scores displayed in our Public Library have not been verified by SafetyCulture for accuracy. Users of our platform may provide a rating or score that is incorrect or misleading. You should independently determine whether the template is suitable for your circumstances. You can use our Public Library to search based on criteria such as industry and subject matter. Search results are based on their relevance to your search and other criteria. We may feature checklists based on subject matters we think may be of interest to our customers.