Nate Schreiber

IDC Safety Champion Observation Form

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Title Page

Observer
Department
Date
Process
Shift
Site conducted

Observations

Personal Protective Equipment

Eye/Face/Head
- Safe
- At Risk
- Discussed
Ears/Hearing
- Safe
- At Risk
- Discussed
Arms/Hands
- Safe
- At Risk
- Discussed
Legs/Foot
- Safe
- At Risk
- Discussed
Protective Clothing
- Safe
- At Risk
- Discussed

Tools and Equipment

Selection
Proper Use
Safe Condition
Guarding

Hoists and Lifting Devices

Safety Latch
Proper Use
Suspended/Unattended Loads

Body Protecting

Line of Fire
Pinch/Crush Points
Trip and Slip Hazards

Ergonomics/Body Mechanics

Lifting/Bending/Twisting
Stand/Sit/Kneel
Reaching/Awkward Positions
Pushing/Pulling/Excessive Force
Stable Positioning/Footing/Grip

Appearance

Clean/Orderly/5S
Clear Access/Escape Routes

Discussion

List positive reinforcement of safe practices that were completed:
List potential corrective actions for at-risk conditions observed:
Open Discussion:

Nate Schreiber

IDC Safety Champion Observation Form

Use this Template

Print as PDF

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