Safe Work Observation Form

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Safe work observation form

• Location
  Address

• Select date

  Date

• Description of works to be undertaken :

• Number of people observed

• Any activity that has the potential to cause serious injury shall be stopped and appropriate corrective action implemented immediately.
  

Observed at risk category PPE

• Head

  Safe

  At Risk

  N/A

• Eyes/face

  Safe

  At Risk

  N/A

• Eyes/face

  Safe

  At Risk

  N/A

• Hearing

  Safe

  At Risk

  N/A

• Respiratory

  Yes

  No

  N/A

• Hand

  Yes

  No

  N/A

• Body

  Yes

  No

  N/A

• Feet

  Yes

  No

  N/A

• Add media

  Media

Observed at risk category Procedure

• JSA / SOP

  Yes

  No

  N/A

• Test n tag in date

  Yes

  No

  N/A

• Pre start checks

  Yes

  No

  N/A

• Job preparation and task instructions

  Yes

  No

  N/A

• Chemical use and understanding

  Yes

  No

  N/A

Observed at risk category working environment

• Housekeeping

  Safe

  At Risk

  N/A

• Barricading

  Safe

  At Risk

  N/A

• Thermal comfort

  Safe

  At Risk

  N/A

• Storage

  Safe

  At Risk

  N/A

• Facility conditions

  Safe

  At Risk

  N/A

• Working conditions

  Safe

  At Risk

  N/A

• Others

  Safe

  At Risk

  N/A

• Others

  Safe

  At Risk

  N/A

Observed at risk category tools/equipment

• Selection

  Safe

  At Risk

  N/A

• Condition

  Safe

  At Risk

  N/A

• Use

  Safe

  At Risk

  N/A

• Current test tag

  Yes

  No

  N/A

• Compliance / lifting,slings,chains,

  Safe

  At Risk

  N/A

Observed at risk category body use/ postion

• Line of Fire

  Safe

  At Risk

  N/A

• Lifting

  Safe

  At Risk

  N/A

• Pushing/pulling

  Safe

  At Risk

  N/A

• Carrying

  Safe

  At Risk

  N/A

• Climbing three point of contact

  Safe

  At Risk

  N/A

• Posture

  Safe

  At Risk

  N/A

• Other

  Safe

  At Risk

  N/A

Mobile equipment

• In good condition

  Yes

  No

  N/A

• Being used correctly, Use

  Yes

  No

  N/A

• Enter /Exit

  Yes

  No

  N/A

• Pedestrian segregation

  Yes

  No

  N/A

• Being used correctly, Use

  Yes

  No

  N/A

• Enter /Exit

  Yes

  No

  N/A

Area of concern / Commendable Safe Behaviours Observed

• Are there any parts of the job that are "Critical"and need to be altered?

  Safe

  At Risk

  N/A

• Identify type of follow up actions required , persons responsible and date for the implementation.

• Select date

  Date

• Officers name

  Sign

• Submit completed form to Safety Officer
  All at risk categories identified will be placed in the OSH progress report for auctioning