Safety Observation Card - Servus

• Site / General Area (e.g. Albion Plaza / Basement Car Park)

• Enter the date and time or use the date time stamp

  Date

Initial Observations

• Rushing to complete task

  Safe

  At Risk

  N/A

• Paying attention to task

  Safe

  At Risk

  N/A

• Balance, Grip, Stable work Surface

  Safe

  At Risk

  N/A

Line of Fire

• A picture paints a thousand words

  Media

• PPE (required, good condition, worn properly, adequate)

  Safe

  At Risk

  N/A

• Body Position (could be struck by, fall over easily, exposed to pinch points etc.)

  Safe

  At Risk

  N/A

• Are adequate guards / screens / signage provided

  Safe

  At Risk

  N/A

• Energy Isolation (Lock Out Tag Out)

  Safe

  At Risk

  N/A

Ergonomics

• Bending, Lifting Twisting

  Safe

  At Risk

  N/A

• Over-reach, excessive pulling or pushing

  Safe

  At Risk

  N/A

• Repetitive Motions

  Safe

  At Risk

  N/A

• Extended standing, sitting or kneeling

  Safe

  At Risk

  N/A

• Does the person look comfortable

  Safe

  At Risk

  N/A

Procedures and Standards

• Are procedures followed

  Safe

  At Risk

  N/A

• Are procedures up to date and understood by the work team

  Safe

  At Risk

  N/A

• Is the work area kept tidy

  Safe

  At Risk

  N/A

Tools and Equipment

• Are tools safe to use (was a pre-inspection or test done)

  Safe

  At Risk

  N/A

• Is it the right tool for the job

  Safe

  At Risk

  N/A

• Is it used correctly

  Safe

  At Risk

  N/A

How can we improve?

• Is a follow up required?

  Yes

  No

  N/A

• What's the potential risk associated with the task?

  High

  Medium

  Low

• Observer's Name (Optional)

  Sign