Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Location

Untitled Page

  • Job Observations

  • Observer:

  • Task:

  • Plant/Area:

  • Date/Time:

  • Supervisor(s):

  • Operator(s):

  • Intervene

  • Ergonomics/Body Use and Position

  • Lifting with legs/knees rather than back

  • Full body turn rather than twisting

  • Smooth motions

  • Walking/Working

  • Eyes in direction of travel

  • Not walking backwards

  • Not rushing

  • Ladders and Climbing

  • Using ladders or steps

  • Using handrail if walking up and down steps

  • Not climbing on equipment

  • Both hands free when climbing

  • Ladder tied off

  • One person on ladder at a time

  • Inspected daily

  • Using 3 points of contact

  • Stable surface/Secure Positon

  • Working on a stable surface

  • Is footing secure

  • Working away from edge or opening

  • Not working directly below robot

  • Pinch Points

  • Body parts clear of moving machinery

  • Body parts clear of magnet wheels

  • Tight space/sharp or hot surfaces

  • Body parts not in close proximity

  • Personal Protective Equipment (PPE)

  • Hard hat used and in good condition

  • Face shield used and in good condition

  • Safety glasses used and in good condition

  • Safety boots used and in good condition

  • FR clothing used and in good condition

  • Proper clothing used and in good condition

  • Proper gloves used for task and in good conditon

  • Respirator storage used when not in use

  • Respirator used and in good conditon

  • Clean shaved when wearing respirator

  • Proper respirator cartidge used and in good condition

  • Hearing protection used and in good condition

  • Fall Protection

  • Harness and lanyard used properly and in good condition

  • Inspection current

  • Fall Hazard Assessment accurate

  • Anchorage point adequate

  • Harness and lanyard tied off properly

  • 100% tie off being maintained above 4 feet

  • Scaffold rosettes not being used for tie off

  • Harness and lanyard off ground when not in use

Tools and Equipment

  • Not Appicable

  • Intervene

  • Is the right tool/equipment used correctly

  • Is tool/equipment in good condition

  • Are generators away from workers

  • Are tools/objects/equipment safe from being dropped


  • Inspection current

  • Exposed electrical parts


  • Is equipment deenergized

  • All energy isolated, disconnected, blanked.etc

  • Are tags filled out correctly

  • Are locks on equipment

  • Are procedures followed

  • Was verification adequate and done


  • Are GFCI's used and placed at outlet source

  • Have GFCI's been tested

  • Are all cords out of water

  • Have electrical cords been inspected

  • Are electrical cords free of damage

  • Are cords routed properly ouyt of walkways

Confined Space Attendant

  • Attendant in place with no collateral tasks

  • Aware of method for communicating with entrants

  • Has continuous monitoring documented

  • Knows rescue plan requirements and how to summon

  • Is not breaking the plane of the space

  • Has monitor inside of the confined space

  • Accurate logs kept for entrants into and out of space

Confined Space Entry Supervisor

  • Any confined space has been checked before entry

  • Has form posted at confined space entrance

  • Ensures permit is properly filled out/logs kept/monitoring

  • Resue team in place before entry

  • Ensures attendant is relieved when asked

  • Air movers/blowers are in place

  • Ensures customer confined space form is adequate

  • Attendant is in place prior to entry

  • Is all emission equipment away from entrance of space


  • Scaffold has been inspected each shift/day

  • Scaffold tags are in place and accurate

  • Items are not stacked where dropped objects can occur

  • Requirements followed that are listed on scaffold tag

  • Not signed off by a Gecko Employee

  • Swing gates remain closed when not in use

Barricades and Tags

  • Are all sides barricaded

  • Barricade covers entire area of need

  • Are tags on all 4sides

  • Are tags filled out correctly

  • Is all equipment captured in barricade

  • Is falling water staying within barricade

  • Correct color being used

Job Safety Analysis/Hazard Assessment/Permits

  • All permits obtained from customer

  • Permits properly filled out

  • Permit signed by everyone as needed

  • Permits properly communicated

  • Area evaluated properly

  • Following procedures indicated on JSA

  • Knows information on JSA form (Ask employee)

Hazard Communication

  • All chemical containers labeled


  • All customer environmental concerns met

  • Water not piling up in work area

Vehicle Truck/Rental

  • Are seat belts being worn

  • Is it being driven at safe speed

  • Is driver alert/looking in direction of travel

  • Is load being carried correctly

  • Inspection current on vehicle

  • Cargo secured properly


  • Worker has proper training to use it

  • Daily inspection sheet complete and current

  • Equipment on stable/level surface

  • Employee 100% tied off while in it

  • Spotter used in congested areas

  • Workers not standing on handrails

  • Worker at controls while lift is in use

  • Exiting lift while elevated remaining tied off

CUSTOMER NOTES (Has customer provided safe work environment?)

  • Notes

SUPERVISOR NOTES (Unsafe Acts and Behaviors)

  • Notes

OPERATORS NOTES (Unsafe Acts and Behaviors)

  • Notes

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.