HSE Observation Form

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

General Information

• Select date

  Date

• Place of Observation

• Work Description

• JSEA #

• Duration

• Number of people being observed

• Number of Observers

Observation team

• Full Name and Position

Observations

Work Environment/Conditions

• Housekeeping and Layout

  Safe

  At Risk

  Not Observed

• Securing of Equipment

  Safe

  At Risk

  Not Observed

• Barricades and Signage

  Safe

  At Risk

  Not Observed

• Environmental Controls

  Safe

  At Risk

  Not Observed

Systems/Standards/Procedures

• Lock-out & Tag-out

  Safe

  At Risk

  Not Observed

• Work Permits

  Safe

  At Risk

  Not Observed

• Competence for task

  Safe

  At Risk

  Not Observed

JSEA/SOP/WI/Pre Start Check/MSDS

• Available?

  Yes

  No

  N/A

• Adequate?

  Yes

  No

  N/A

• Understood?

  Yes

  No

  N/A

• Followed

  Yes

  No

  N/A

Tools and Equipment

• Condition

  Good

  Poor

  N/A

• Availability

  Good

  Poor

  N/A

People/Behaviour

Positions

• In, On or Between

  Safe

  At Risk

  Not Observed

• In the Line of Fire

  Safe

  At Risk

  Not Observed

Actions

• Exerting or Rushing

  Safe

  At Risk

  Not Observed

• Ascending or Descending

  Safe

  At Risk

  Not Observed

• Loading, Lifting or Handling

  Safe

  At Risk

  Not Observed

• Working at Heights

  Safe

  At Risk

  Not Observed

• Communication

  Safe

  At Risk

  Not Observed

Protection

• Use of P.P.E

  Good

  Poor

  N/A

• Electrical Hazards

  Safe

  At Risk

  Not Observed

• Hazardous Substances

  Safe

  At Risk

  Not Observed

• Other Energy Sources

  Safe

  At Risk

  Not Observed

Tools/Equipment/Machinery

• Tools and Equipment

  Good

  Poor

  N/A

• Vehicles & Machinery

  Good

  Poor

  N/A

Good Observations

• Category and Observation

At-Risk Observations

• Category and Observation

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