Information

  • Observer:

  • Company:

  • Conducted on:

  • Location

Information

  • Observer:

  • Company:

  • Coached by:

  • # of People Observed:

  • Dept. Observed:

  • Company Observed:

  • Select date

  • Hours into Shift:

  • Shift:

  • Task of Month:

  • Process Condition:

W.H.A.T

  • SIF Potential:

  • Self Observation

Body Position

  • 1.01 Line of Fire

  • 1.02 Pinch Points

  • 1.03 Eyes on Task / Path

Body Use / Ergonomics

  • 2.01 Lifting / Twisting Mechanics

  • 2.02 Work Pace / Assistance

  • 2.03 Force & Exertion / Repetition

Tools & Equipment

  • 3.01 Equipment Use

  • 3.02 Tool Selection, Condition, Use

Procedures

  • 4.01 P.J.H.A / W.H.A.T

  • 4.02 Rail or Mobile Equipment Use

  • 4.03 Elevated Work

  • 4.04 Lockout / Tagout

  • 4.05 Confined Space

  • 4.06 Communication of Hazard / Permit

  • 4.07 Hot Work

Food Safety

  • 5.01 FS Process & Equipment Operation

  • 5.02 FS Sanitary & Hygenic

  • 5.03 FS Personnel Behaviors

PPE

  • 6.01 Standard PPE

  • 6.02 Specialized PPE

Work Environment

  • 7.01 Walking / Working Surfaces

  • 7.02 Housekeeping / Storage

  • 7.03 Barricades / Guards

  • 7.04 Ascending / Descending

  • 7.05 Temperature Extremes / Weather

  • 7.06 Lighting

Safe Comment - Identify notable safe behaviors

  • CBI#

  • WHILE and where

  • WHAT the employee did to remain safe

At-Risk Comments

  • CBI#

  • WHILE and where

  • WAS and potential hazard

  • BECAUSE

  • SOLUTION

  • Solution from employee?

  • TRY the solution?

  • Barrier Removed?

  • If impossible to do safely, what will be done in the meantime?

  • Aware of Behavior?

  • Follow-up?

  • Behavior:

At-Risk Comments

  • CBI#

  • WHILE and where

  • WAS and potential hazard

  • BECAUSE

  • SOLUTION

  • Solution from employee?

  • TRY the solution?

  • Barrier Removed?

  • If impossible to do safely, what will be done in the meantime?

  • Aware of Behavior?

  • Follow-up?

  • Behavior:

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.