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Reason For Observation
Incident Follow up
High Visabillity Clothing
Steel Toe Boots
Personal Safety Assessment
5x5 Filled out?
JHA completed for the task at hand?
1. Safe Practices Observed:
Substandard Acts Observed:
Sub Standard Observations
Standards, Procedures, Work Instructions, JRA:
Nothing in place
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to
take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment;
or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is
permissible in your workplace or jurisdiction.
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