Title Page
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EMPLOYEE NAME
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OBSERVER NAME
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DATE OF OBSERVATION
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PREPARED BY
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LOCATION OF OBSERVATION
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INSTRUCTIONS:
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1. Answer “OK”, “Deviation”, or “Not Applicable” per the results of the observation. If the activity was not observed during this observation, select N/A.
2. For any deviation noted, enter a brief description using the paperclip icon "Add Notes". Immediately correct unsafe work conditions by using "Add Action". Stop any work that appears imminently dangerous. Repair, replace, or temporarily.
3. Complete audit by providing digital signature.
4. Share your report by exporting as PDF, Word, Excel or Web Link. -
BRIEF DESCRIPTION OF WORK ACTIVITIES PERFORMED DURING OBSERVATION
PERS. PROT. EQUIPMENT
PRE-WORK / WORK AREA PLANNING
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Employee/company vehicle properly and safely parked.
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Arrival notification provided to customer/designee (sign-in, etc.). Employee aware of where access is permitted, restricted or prohibited.
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Employee aware of how to reach customer or site contact (as well as direct supervisor) for questions, reporting of safety/work area concerns, etc.
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Employee conducts survey of site and work area hazards and establishes safe access and controls before beginning work activities.
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Employee is familiar with any available customer emergency and/or safety procedures, including accountability after emergency evacuation.
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Slip, trip, and fall hazards evaluated, avoided, minimized, and/or adeqautely controlled.
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Chemical, radiological, biological, communicable disease, and similar exposure hazards avoided, minimized, and/or adeqautely controlled.
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PPE available, appropriate, and utilized for tasks performed.
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Select PPE in use.
- Foot protection (safety-toed, slip-resistant, other)
- Eye and face protection (safety glasses, goggles, face shield, welding helmet, other…)
- Head protection (hard hat, bump cap, other)
- Hand protection (leather gloves, electrical insulating gloves, chemical resistant gloves, cut-resistant gloves, other…)
- Body protection (welding, electrical work, cut-resistant protection, cold suit, other…)
- Hearing protection (ear plugs, muffs, other…)
- Fall protection (harness, lanyard, anchoring equipment, other…)
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Employee demonstrates understanding of job tasks and/or hazards requiring additional and/or different PPE.
GENERAL
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Housekeeping controls established. Work area maintained in a neat and orderly condition.
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Tools properly selected for the job task. Tools in good condition and/or guarded where required.
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Extension cords in good condition and used in a manner so as not to create a hazard. Ground fault circuit interrupters used.
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Proper lifting and carrying techniques demonstrated. Employee avoids working in awkward postures whenever possible.
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Ladders in good condition. Pre-use inspection performed. Proper type of ladder used for the work performed and load. Safe work practices enacted for ladder placement and security.
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Employee knows where to obtain MSDS. Chemicals handled, stored, used, and disposed of properly. Chemicals labeled properly.
SPECIAL RISKS & CONSTRUCTION
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Elevated Work - safe access to work area established, pre-use inspection of all equipment completed (fall protection equipment, system, etc),and safe work practices used (including procedure for getting tools and equipment to work surface).
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Floor and wall openings are covered and/or barricaded, perimeter protection in place, deck planks secured, materials stored away from edge.
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Scaffolding inspected daily, rails in place (guardrails, intermediate rails, toeboards), planking in good condition, persons below protected from falling objects, competent person identified.
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Powered Industrial Equipment – proper license/certification available and current. Load rating/capacity known. Inspection documentation available.
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Confined Space Entry - entry procedure available, appropriate test equipment and ventilation established, permit available and in use, training current.
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Hot work (welding, cutting, brazing) - safe practices enacted, permit used, fire extinguisher available, equipment in good condition, appropriate PPE available and used.
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Work near trenching/excavations - marked, protected, safe work procedures enacted.
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Hoisting equipment, chains, and slings in good condition, inspected prior to use, load rating known and appropriate for task, safe work practices enacted.
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Work near cranes – persons kept from under suspended loads and crane swing/work area, employees certified/licensed.
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Attic spaces – pre-work hazard review performed, adequate illumination established, safe work practices enacted.
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Residential sites - verification that pets are secure prior to premises entry or performance of work activities.
LIVE ELECTRICAL WORK
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Are Lockout/Tagout Devices available & used for exposure to other hazardous energy sources or exposed, unguarded, and/or moving parts & proper de-energization verified by supervisor.
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Has a Live Electrical Work Permit been completed for energized circuit above 50 volts and has the permit been reviewed and approved by the Supervisor?
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Is employee properly trained, can distinguis exposed electrical parts, determine nominal voltage & understands decision making process to the degree and extent of the Hazard.
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All electrical hazards identified prior to starting work, safe work practices enacted and appropriate rated PPE and Tooling available and being used.
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If required has the Arc Flash Protection Boundary been established and barricaded to prevent unqualified personnel from entering while equipment is exposed.
