Title Page
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Document No.
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Prepared by
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Location of work:
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Type of work:
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Personnel
Unsafe Actions
Reactions of People
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Are they using appropriate PPE for the task?
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Are they modifying their position in relation to the task?
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Are they rearranging the job to perform it safely?
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Are they stopping the job if it can not be performed safely?
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Are they performing LockOuts if required?
Personal Protective Equipment Head-to-Toe Check
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Head
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Eyes and Face
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Ears
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Respiratory System
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Arms and Hands
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Trunk
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Legs and Feet
Positions of People
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Striking against or being struck by objects
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Caught in, on or between objects
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Falling
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Contacting Temperature Extremes
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Contacting Electric Current
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Inhaling, absorbing or swallowing a hazardous substance
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Repetitive motions
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Awkward Positions or static postures
Tools and Equipment
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Right tool for the job
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Used Correctly
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In safe condition
Procedure
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Available
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Adequate
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Known
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Understood
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Followed
Unsafe Condition
Tools and Equipment
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Are they right for the job
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Are they in safe condition
Work area/Environment
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Is it clean
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Is it orderly
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Is it in safe condition
Constructive Feedback and Positive Reinforcement
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Safe Acts Observed:
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Unsafe Acts Observed:
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Observation Completed on:
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Name of the employee observed:
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I provided the employee with feedback regarding this safety observation.
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Observation Completed by:
