Title Page

  • Site conducted

  • Employee Name and Department (completing checklist)

  • Task / Area being observed

  • Type of Observation

  • Date and Time of observation

  • Prepared by

  • Location


  • Reason for observation

  • Specify

  • Task Description

  • Major / Primary steps required to complete task


  • Is special PPE require?

  • Is Lock-Out required?

  • Is a Risk Assessment required?

  • Are there any special instructions from the supervisor for the employee for completing this task?

  • Is the SLAM completed correctly?

  • Is the Work Permit and DSTI completed correctly?

  • Could any of the observed practices / conditions result in property damage, personal injury or illness?

  • If yes, describe

  • Where the methods and practices observed the most efficient and productive?

  • If No, describe

  • Did the practices observed comply with all of the applicable procedures or standards that exist for the task?

  • If No, describe

  • Did you observe any practices or aspects of the task that where improvements which deserve recognition?

  • If yes, describe

  • Describe bellow observed practices that require correction or improvement

  • Have you corrected or complimented the worker base on these observations?

  • Should a follow up observation of this area, task or person take place?

  • If yes, describe who and why ?

  • Describe any standard procedures, methods or equipment you observed that should be changed in the interest of safety and / or productivity


  • Details

  • Who

  • When

  • Inspection Participants
  • Name and Signature

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.