Title Page
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Property
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Department
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Observation Date
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Observer
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Task
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Employee
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Select One
- New Employee (<90 days)
- Returning from injury
- In job > 5 years
- Discomfort
- Disregard safe practice
- Other
If NO is checked, you must select a reason for the AT RISK BEHAVIOR OR CONDITION and include corrective action on the following page. ST: Safety Training Not Provided within the last 12 months or documented SP: Safe Practice (Training) Not Followed JD: Job Design
Behavioral Risk Factors
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Moves at reasonable pace (not too quickly/aggressively)
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Select One
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Requests help to reduce pace of work being performed.
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Details of Observation
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Operates within authority and job description
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Select One
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Refuses to attempt task that s/he is not trained/qualified to complete safely. Supervisor notified. Employee replaced with one who has proper training.
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Details of Observation
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Follows written/oral procedures or instructions
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Select One
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Retraining provided and documented
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Details of Observation
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Uses sharp and proper cutlery, knife, tool for job
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Select One
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Inspects knives, tools for damage or wear before use. Monitors sharpening schedule.
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Details of Observation
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Wears proper type and size of personal protective equipment (goggles, face shield, cut-resistant gloves)
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Select One
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Wears all proper PPE before starting task.
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Details of Observation
Conditions / Environmental Risk Factors
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No potential for handling broken glassware, ceramics
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Select One
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Notifies supervisor; wears gloves during handling glass; use brush or tools to pick up broken glass; dispose of glass in proper waste container
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Details of Observation
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No potential for handling needles or sharps (knife/razor blades)
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Select One
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Notifies supervisor or trained bio-hazard clean-up team member; if authorized/trained, disposes of needles/sharps in proper sharps container; wears protective gloves before clean-up is attempted.
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Details of Observation
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Uses machines (slicer/power tools) with proper guards in place
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Select One
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Notifies supervisor or engineering department. Refuses to use unguarded equipment until properly equipped. Locked/tagged out of service.
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Details of Observation
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Equipment, tools, carts are free from sharp or broken edges, surfaces
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Select One
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Notifies supervisor and engineering department. Replace defective equipment/tools/carts
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Details of Observation
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Adequate maintenance of walking surfaces (holes, cracks, loose material)
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Select One
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Notifies supervisor and engineering department. Mark area with warning cone, tape and/or signs.
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Details of Observation
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Comments regarding observations - positive reinforcement or corrective action for AT RISK BEHAVIORS AND CONDITIONS - ST, SP, JD.
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Date of Coaching
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Employee Initials
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Supervisor/Manager Initials
