Jacobs_SOR_ROSS

Safety Observation Report (SOR)

• Conducted on

  Date

• Date Corrected

  Date
• Location
  Address

• What was observed:

SOR

Observation

• Imminent Danger

  Yes

  No

  N/A

• Date/Time:

  Date

• Observation Type:

  Select Unsafe Act Safe Act Unsafe Conditions Safe Conditions

  • Unsafe Act
  • Safe Act
  • Unsafe Conditions
  • Safe Conditions

• Add media

  Media

Action Taken:

• Add media

  Media

• Date/Time Action Taken:

  Date

Action(s) to prevent recurrence:

Indirect Cause:

• Training

• Resources

• Belief

Further action or help needed:

Checklist Items:

• Housekeeping:

  Select Trash Tripping Hazards Cords Material Storage Access N/A

  • Trash
  • Tripping Hazards
  • Cords
  • Material Storage
  • Access
  • N/A

• Fall Protection:

  Select Railings Tie-Offs Anchorage PPE Inspection N/A

  • Railings
  • Tie-Offs
  • Anchorage
  • PPE
  • Inspection
  • N/A

• Scaffolds, Ladders, Stairways:

  Select Inspect Tag Position Tie-off N/A

  • Inspect
  • Tag
  • Position
  • Tie-off
  • N/A

• Personal Protective Equipment:

  Select Head Face Hands Hearing Feet Clothing N/A

  • Head
  • Face
  • Hands
  • Hearing
  • Feet
  • Clothing
  • N/A

• Excavations:

  Select Inspected Slope/Benched Shore Vibration Air Tested Permit N/A

  • Inspected
  • Slope/Benched
  • Shore
  • Vibration
  • Air Tested
  • Permit
  • N/A

• Material Handling:

  Select Hoisting Rigging Proper Use Inspection N/A

  • Hoisting
  • Rigging
  • Proper Use
  • Inspection
  • N/A

• Vehicles, Mobile Equipment:

  Select Inspections Operation N/A

  • Inspections
  • Operation
  • N/A

• Tools and Equipment:

  Select Selection Use Maintenance N/A

  • Selection
  • Use
  • Maintenance
  • N/A

• Fire Protection:

  Select Ignition Control Permit Extinguishing Equipment Watch Training N/A

  • Ignition Control
  • Permit
  • Extinguishing Equipment
  • Watch Training
  • N/A

• Confined Space:

  Select Permit Testing Attendant Training Retrieval Equipment N/A

  • Permit
  • Testing
  • Attendant Training
  • Retrieval Equipment
  • N/A

• Planning, Communication:

  Select Communications Safe Plan of Action (SPA) Resources Toolbox Safety Meeting N/A

  • Communications
  • Safe Plan of Action (SPA)
  • Resources
  • Toolbox Safety Meeting
  • N/A

• LO/TO and Electrical:

  Select Verify Energy Control Steps GFCI Cords N/A

  • Verify Energy Control Steps
  • GFCI
  • Cords
  • N/A

• Work Practices:

  Select Body Position Cheaters Pinch Points Proper Tools N/A

  • Body Position
  • Cheaters
  • Pinch Points
  • Proper Tools
  • N/A

• Chemical Exposure:

  Select Hazard Communication Air Monitoring H2S Meter N/A

  • Hazard Communication
  • Air Monitoring
  • H2S Meter
  • N/A

• Permit / Hazard Evaluations:

  Select Permit Complete Hazard ID Effective Controls N/A

  • Permit Complete
  • Hazard ID
  • Effective Controls
  • N/A

• Other:

  Positive

• Description of Other Line Item:

• Signature

  Sign