Safety Observation & Engagement

• Site conducted
  Address

• Conducted on

  Date

• Prepared by

• Location

Section 1 - Observation & Engagement Snapshot

• Task Observed

• Observation Category

  Select PPE Ergonomics Tools & Equipment Policies & Procedures Housekeeping Other

  • PPE
  • Ergonomics
  • Tools & Equipment
  • Policies & Procedures
  • Housekeeping
  • Other

• Observed Behavior

  Safe

  At Risk

  N/A

• Observed Conditions

  Safe

  At Risk

  N/A

• Overall Performance

  Good

  Fair

  Poor

  N/A

• Reviewed & Discussed Observation with Employee

  Yes

  No

  N/A

• Employee Response

• Observer Statements (e.g. questions, positive recognition, etc.)

Section 2 - Assessment & Review

• Work Instructions, Policies & Procedures and JHA’s have been reviewed and verified?

  Yes

  No

  N/A

• PPE is being properly utilized (safety glasses, footwear, clothing, etc.)?

  Yes

  No

  N/A

• Body is positioned to prevent line-of-fire, pinch/crush point, balance and repetitive motion injuries?

  Yes

  No

  N/A

• Performed visual or documented all Pre-Use Inspections for tools/machines being used?

  Yes

  No

  N/A

• Tools are in good condition and are proper for task being performed?

  Yes

  No

  N/A

• Housekeeping satisfactory (trash and debris, tripping hazards, etc.)?

  Yes

  No

  N/A

• Chemical hazards have been removed (inhalation, ingestion, skin contact, injection)?

  Yes

  No

  N/A

• Recognizes all hazards associated with task being performed?

  Yes

  No

  N/A

• No electrical hazards are present (frayed electrical lines, exposed wires, circuit overload, etc.)?

  Yes

  No

  N/A

• Task completion being accomplished in accordance with Work Instructions, Policies & Procedures , JSA’s, and all other required guidelines?

  Yes

  No

  N/A

• Understands Emergency Response and Incident Reporting Procedures (assembly areas, alarms, etc.)?

  Yes

  No

  N/A

• Employee keeping Mind and Eyes on Task (no allowance of outside influences or distractions)?

  Yes

  No

  N/A

Section 3 - Opportunities for Improvement

• Corrective Action(s) Required

  Yes - Complete Section 3

  No -Go to Section 4

• List Corrective Action(s)

• Responsible Person for Corrective Action(s)

• Corrective Action(s) Completion Date

  Date

• Report Sent to Responsible Person(s)

  Yes

  No

  N/A

• Corrective Action(s) Completed & Closed

  Yes

  No

  N/A

• Risk Assessment Required

  Yes

  No

  N/A

Section 4 - Observer Self-Assessment

• Did you engage with others (e.g. discussion, review, problem solving).

  Yes

  No

  N/A

• List Some Specific Examples

• Explanation & Reasoning

• Was a Positive Recognition issued (e.g. safe work procedure, safe behavior, etc.)?

  Yes

  No

  N/A

• Please Explain & List Details

• Did you Pre-Plan this Observation & Engagement?

  Yes

  No

  N/A

• Please Explain

• Did you assess the risks & hazards of the area & personnel practices?

  Yes

  No

  N/A

• Please Explain

• Did you discuss follow-up actions & assign the responsible personnel?

  Yes

  No

  N/A

• Please Explain

• Were all assigned & responsible personnel informed & agreeable to Corrective Actions?

  Yes

  No

  N/A

• Please Explain

Section 5 - Closure & Conclusion

• Employee Comments or Suggestions

• Observer Final Comments & Recommendations

• Reviewer Signature

• Observed Signature

• Date

  Date