South West Safety Observation Form Copy

• Name

• Today's Date

  Date

• Employee Division

  Select Institutional Vic Institutional SA Institutional WA

  • Institutional Vic
  • Institutional SA
  • Institutional WA

• Observation Date

  Date

• Time

• Location
  Address

Choose A Category From List Below

• Unsafe Act

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  On

• Choose One Or More By Tapping Lines At Right Side Of This Box

  Select Not Following Policy or Procedure Using PPE Improperly Operating/Servicing equipment under pressure Failure to warn Tampering with Safety Devices Distracted While Driving Under the influence of alcohol, drugs or fatigue Servicing Equipment in Use Operating equipment without authority or training Improper Lifting or Loading

  • Not Following Policy or Procedure
  • Using PPE Improperly
  • Operating/Servicing equipment under pressure
  • Failure to warn
  • Tampering with Safety Devices
  • Distracted While Driving
  • Under the influence of alcohol, drugs or fatigue
  • Servicing Equipment in Use
  • Operating equipment without authority or training
  • Improper Lifting or Loading

• Unsafe Conditions

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  On

• Choose One Or More By Tapping Lines At Right Side Of This Box

  Select Congested or Restricted Area Inadequate Guards or Barriers Weather Inadequate or Improper PPE Poor Housekeeping/Disorderly Area Inadequate/Excessive Illumination or Noise Defective Tool Equipment or Material High or Low Temperature Exposure/Substances Leaks in Water or Chemical Pipes or System Visible Air Emissions or Spills to Soil and Water Fire and Explosion Hazard inadequate Ventilation inadequate Warning System Open Leaking or Damaged Chemical Containers Unlabeled Incorrectly labelled Chemical/Waste Containers

  • Congested or Restricted Area
  • Inadequate Guards or Barriers
  • Weather
  • Inadequate or Improper PPE
  • Poor Housekeeping/Disorderly Area
  • Inadequate/Excessive Illumination or Noise
  • Defective Tool Equipment or Material
  • High or Low Temperature Exposure/Substances
  • Leaks in Water or Chemical Pipes or System
  • Visible Air Emissions or Spills to Soil and Water
  • Fire and Explosion Hazard
  • inadequate Ventilation
  • inadequate Warning System
  • Open Leaking or Damaged Chemical Containers
  • Unlabeled Incorrectly labelled Chemical/Waste Containers

• Safe Act/condition

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  On

• Choose One Or More By Tapping Lines At Right Side Of This Box

  Select Significant Safety Process Improvement Safety Leadership Displayed Intervention of an Unsafe Act Elimination of a Workplace Hazard

  • Significant Safety Process Improvement
  • Safety Leadership Displayed
  • Intervention of an Unsafe Act
  • Elimination of a Workplace Hazard

• Other

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• Details if Other Selected

Details Of Observation

• Details (Add photo if required)

List Actions Taken During / Following Observation

• Details

Further Action Requested

• action

Add Action

• Description Of Further Action

• Due Date

  Date

• Assigned To