SAFE ACT OBSERVATION (SAO)

• Document No. - ICE-ECD-058

• Project Number -

• Client / Site

• Conducted on

  Date

• Completed by -

• Location
  Address

• Personnel

OBSERVATION QUESTIONS

• Have you completed a take 5?

  Select YES NO N/A

  • YES
  • NO
  • N/A

• IF NO STOP WORK AND COMPLETE THE TAKE 5 FOR THE TASK?

  Select OK N/A

  • OK
  • N/A

• How many Take 5's have you completed this week.

• Have you been trained to perform the task?

  Yes

  No

  N/A

• IF NO STOP WORK AND CONTACT YOUR SUPERVISOR

  OK

  N/A

• Have you got a copy of the JSEA?

  Yes

  No

  N/A

• IF NO STOP WORK AND ENSURE A COPY OF THE JSEA IS ON SITE , READ AND UNDERSTOOD.

  OK

  N/A

• Is the task you are doing recorded in the JSEA?

  Yes

  No

  N/A

• IF NO STOP WORK AND AMMEND THE JSEA.

  OK

  N/A

• Have all the identified hazards been recorded in the JSEA?

  Yes

  No

  N/A

• IF NO STOP WORK AND AMMEND THE JSEA.

  OK

  N/A

• Areal the controls that have been implemented adequate?

  Yes

  No

  N/A

• IF NO STOP WORK RE-EVALUATE THE CONTROL MEASURES

  OK

  N/A

• Do you feel safe carrying out the task ?

  Yes

  No

  N/A

• IF NO STOP WORK AND DISCUSS

  OK

  N/A

• Is there anything else that could injure you?

  Yes

  No

  N/A

• IF YES STOP WORK AND DISCUSS

  OK

  N/A

• Do you know where the muster point is?

  Yes

  No

  N/A

• What should you do if you hear the emergency alarm sound?

  Yes

  No

  N/A

APPROVAL SIGNATURE

• CEO / HSE Manager Signature / Observation Team

  Sign

• Supervisor Signature

  Sign