• For Month of

  • Observation Time

  • People Observed

  • Job photo


  • Hard Hat

  • Safety Glasses

  • Footwear

  • Respiratory

  • Fall Protection

  • Hearing

  • Hand

  • Clothing

Body Mechanics

  • Lifting

  • Carrying

  • Bending

  • Twisting

  • Reaching

  • Position

  • Balance


  • Communication

  • Line of Fire

  • Pace

  • Mind on Task

  • Eyes on Task

  • Hazard Response

  • Working Blind

  • Housekeeping

Tools & Equipment

  • Condition

  • Proper for Job

  • Safety Devices

  • Per-use Checklist

  • Erected/Installed

  • Storage

Lock & Tag

  • Isolated

  • Tested

  • Locked

  • Tagged

  • Sealed

  • Tried (i.e. jog)

Confined Space

  • Permit Completed

  • Observer Assigned

  • S.A.R. Inside

  • Ventilation

  • G.F.C.I.

  • Egress

Work Package

  • Was the employee given a Work Order?

  • Was a Safety Checksheet completed for the job?

  • Does the worker have the required SOP for the job?

General Comments

  • Describe any practices and or conditions that deserve compliment or correction. If corrected please indicate action/follow-up taken.

  • Comments

  • Signature

  • Signature

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