Health, Safety and Environmental (HSE) Observation Form

Ergonomics (Positions of People):

  • Movements and body positions contribute to good posture of the back, arms, risk, etc.

  • Classify the risk.

  • Corrected on the spot?

  • Work tools and equipment minimize strain.

  • Classify the risk.

  • Corrected on the spot?

  • Lifting and reaching occurs in the power zone

  • Classify the risk.

  • Corrected on the spot?

  • Other: (write in the topic observed)

  • Please provide details on what you observed.

Personal Protective Equipment

  • Eye, head, face, hand, foot or hearing protection.

  • Classify the risk.

  • Corrected on the spot?

  • Fall protection used when working at heights.

  • Classify the risk.

  • Corrected on the spot?

  • Other: (write in the topic observed)

  • Please provide details on what you observed.

Equipment & Work Conditions:

  • Electrical equipment in good condition & electrical cabinets closed.

  • Classify the risk.

  • Corrected on the spot?

  • Nip point guards in place, closed, secured and/or interlocked.

  • Classify the risk.

  • Corrected on the spot?

  • Material handling equipment in good condition and operated safely.

  • Classify the risk.

  • Corrected on the spot?

  • Tools are in good working condition, correct tool for the task is used.

  • Classify the risk.

  • Corrected on the spot?

  • Other: (write in the topic observed)

  • Please provide details on what you observed.

Lock Out/Tag Out

  • Equipment safely locked and tagged out. Zero energy state achieved.

  • Classify the risk.

  • Corrected on the spot?

  • Other personnel in the area are aware of lockout.

  • Classify the risk.

  • Corrected on the spot?

  • Other: (write in the topic observed)

  • Please provide details on what you observed.

Risk Awareness

  • The individual is aware of job task risks and safety controls.

  • Classify the risk.

  • Corrected on the spot?

  • The individual is able to describe safe acts for the job AND perform the job safely.

  • Classify the risk.

  • Corrected on the spot?

  • The individual is able to describe unsafe acts for job.

  • Classify the risk.

  • Corrected on the spot?

  • The individual is able to demonstrate that recent incident corrective actions are complete for their work area. [Enter a description of the recent incident here].

  • Classify the risk.

  • Corrected on the spot?

  • The individual knows the location of the nearest emergency equipment (safety shower, eyewash, etc.). It is accessible.

  • Classify the risk.

  • Corrected on the spot?

  • The individual can explain the most recent tool box or training communication.

  • Classify the risk.

  • Corrected on the spot?

  • Other: (write in the topic observed)

  • Please provide details on what you observed.

Housekeeping

  • Pallets, equipment and other materials are placed in designated areas, cables and hoses are stored safely.

  • Classify the risk.

  • Corrected on the spot?

  • Hazardous materials are labeled, used and stored safely.

  • Classify the risk.

  • Corrected on the spot?

  • Walkways and fire equipment/emergency access routes clear of obstructions.

  • Classify the risk.

  • Corrected on the spot?

  • Walking and working surfaces clear and safe (no tripping hazards, obstructions, etc.).

  • Classify the risk.

  • Corrected on the spot?

  • Other: (write in the topic observed)

  • Please provide details on what you observed.

Environment

  • Water leaks are controlled.

  • Classify the risk.

  • Corrected on the spot?

  • Steam leaks are controlled.

  • Classify the risk.

  • Corrected on the spot?

  • Energy waste is minimized (ex: unattended machines are not left running)

  • Classify the risk.

  • Corrected on the spot?

  • Air leaks are controlled.

  • Classify the risk.

  • Corrected on the spot?

  • Drains are blocked to prevent food waste discharge.

  • Classify the risk.

  • Corrected on the spot?

  • Other: (write in the topic observed)

  • Please provide details on what you observed.

Other Observations.

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