Jacobs - Safety Observation Report (SOR)

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Select date

  Date

• Observation

• IMMINENT DANGER

  Yes

  No

  N/A

• What immediate corrective action was taken?

• Action(s) to prevent recurrence

Direct cause (check those that apply)

• Unsafe act

  Off

  On

• Safe act

  Off

  On

• Unsafe condition

  Off

  On

• Safe condition

  Off

  On

Basic cause due to organizational failure to:

• Plan

  Off

  On

• Direct

  Off

  On

• Organize

  Off

  On

• Control Human and material resources

  Off

  On

Indirect cause(s) due to lack of:

• Training

  Off

  On

• Resources

  Off

  On

• Belief

  Off

  On

• Signature

  Sign