Jacobs - Safety Observation Report (SOR) - duplicate

• 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)

• Safe act

  Yes

  No

  N/A

• Safe condition

  Yes

  No

  N/A

Basic cause due to organizational failure to:

• Plan

  Yes

  No

  N/A

• Direct

  Yes

  No

  N/A

• Organize

  Yes

  No

  N/A

• Control Human and material resources

  Yes

  No

  N/A

Indirect cause(s) due to lack of:

• Training

  Yes

  No

  N/A

• Resources

  Yes

  No

  N/A

• Belief

  Yes

  No

  N/A

• Signature

  Sign