Safety Observation Report - duplicate

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Truck and location description

• Type of location

  Select Road Observation Job or Construction Site

  • Road Observation
  • Job or Construction Site

• Job Name

• Truck Number

• Vehicle condition

  Select Clean Dirty

  • Clean
  • Dirty

• Container Number

• Trailer Number

• Approximate time observed

• Traveling direction

  Select North South East West Northeast Northwest Southeast Southwest

  • North
  • South
  • East
  • West
  • Northeast
  • Northwest
  • Southeast
  • Southwest

• Highway or Road Name

• Highway or Roadway conditions

  Select Divided Cement Black Top Smooth Rough Level Winding Upgrade Downgrade Dry Wet Icy

  • Divided
  • Cement
  • Black Top
  • Smooth
  • Rough
  • Level
  • Winding
  • Upgrade
  • Downgrade
  • Dry
  • Wet
  • Icy

• Traffic Conditions

  Select Heavy Medium Light

  • Heavy
  • Medium
  • Light

• Weather and Driving conditions

  Select Daylight Dark Sunset Sunrise Rain Snow Sleet Fog Wind

  • Daylight
  • Dark
  • Sunset
  • Sunrise
  • Rain
  • Snow
  • Sleet
  • Fog
  • Wind

Driver Performance

• Posted Speed limit

• Drivers speed

• Speed verified by

  Select Car Radar Ride along

  • Car
  • Radar
  • Ride along

• Is cargo secured

  Yes

  No

  N/A

• Is cargo covered

  Yes

  No

  N/A

• Communicate intensions well with others

  Yes

  No

  N/A

• Looks for overhead power lines

  Yes

  No

  N/A

• Performs safe lane changes

  Yes

  No

  N/A

• Keeps a safe following distance

  Yes

  No

  N/A

• Performs job task correctly

  Yes

  No

  N/A

• Was wearing seatbelt at all times

  Yes

  No

  N/A

• Used 3 point contact when entering and exiting vehicle.

  Yes

  No

  N/A

• Was wearing personal protective equipment as required

  Yes

  No

  N/A

• Correct procedures were followed at job site, landfill, or yard

  Yes

  No

  N/A

• Safe operation

  Yes

  No

  N/A

Truck Condition

• Headlights were working

  Yes

  No

  N/A

• Tail lights were working

  Yes

  No

  N/A

• Clearance Lights were working

  Yes

  No

  N/A

• Brake lights were working

  Yes

  No

  N/A

• Turn signals were working

  Yes

  No

  N/A

• Reflectors are in good condition

  Yes

  No

  N/A

• Mud flaps are in place and in good condition

  Yes

  No

  N/A

• Wheels,tires are in good condition

  Yes

  No

  N/A

Corrective Actions

• List actions taken

• Select date

  Date

• Add signature

  Sign