Title Page

  • Project Name

  • Project #

  • Location
  • Date and Time

  • Observer Name

  • Observee Name

  • Task Observed

  • Description of Task Observed and Background Information


  • 1. Hearing Protection (e.g., Ear Plugs)

  • 2. Head Protection (e.g., Hard Hat)

  • 3. ANSI Rated Eye Protection (e.g., Safety Glasses)

  • 4. Hand Protection (e.g., Kevlar Gloves)

  • 5. Foot Protection (e.g., Safety Shoes)

  • 6. Respiratory Protection

  • 7. Fall Protection Inspected (e.g., Harness)

  • 8. ANSI Rated Reflective Vest/High Visibility Clothing

  • 9. Other ( Specify)


  • At Minimum, One Employee Per Shift Currently Certified in First Aid & CPR


  • Are the Trailer Wheels Chalked?

  • AED Defibrillator Location is Marked, Readily Accessible and Inspected Monthly

  • Eye Wash Station Location is Marked, Readily Accessible and and Inspected Monthly

  • First Aid Kit Location is Marked, Readily Accessible and and Inspected Monthly

  • Fire Extinguisher Location is Marked, Readily Accessible and Monthly Inspection is current


  • 1. Correct Body Positioning When Lifting/Pushing/Pulling

  • 2. Pinch Points Identified Body/Appendages Clear

  • 3. 3-Points of Contact when ascending and descending ladders

  • 4. Other (Specify)


  • 1. Work/Walk Surface Are Free of Obstructions (e.g., Tripping Hazards)

  • 2. Housekeeping/Storage

  • 3. Defined and Secured (e.g., warning devices, barricades, cones, flags)

  • 4. Lift Area / Drop Zone is Identified and Barricaded

  • 6. Proper Storage & Labeling /Disposal of Sample & Waste Materials

  • 7. Cylinders Stored Upright, Secured, & Caps in Place

  • 9. Other (Specify)


  • 1. HASP is readily available and has been signed

  • 2. JSA Reviewed & Signed

  • 4. Hazard Assessment - Hazard Hunt

  • 5. Other (Specify)


  • Trailer Power Supply Electrical Cord Has Been Inspected and is free of cracks, cuts, frayed wires, no exposed live parts, exposed metal, or splices and the plug is not defective

  • 1. Employee has been trained / certified to operate motorized equipment

  • What is the equipment type?

  • 2.Employee has been trained and is current on fall protection types and use.

  • What is the name of the employee(s) and date(s) of most current Fall Protection training?

  • 3. Ladders are Inspected & Set Up Correctly

  • 6. Other (Specify)


  • Personal Factor:
    (1) Lack of skill or knowledge
    (2) Correct way takes more time/requires more effort
    (3) Shortcutting standard procedures is rewarded or appreciated
    (4) In past, did not follow procedures or acceptable practices and no incident occured

    Job Factor:
    (5) Lack of or inadequate operational procedures or work standards
    (6) Inadequate communication of expectations or work standards
    (7) Inadequate tools or equipment

  • At-Risk Observation
  • At-Risk Observation #

  • Root Cause Analysis #

  • Solution(s) To Prevent Potential Incident from Occuring

  • Person Responsible

  • Agreed Due Date

  • Date Completed

  • Results of Verification (were solutions done?) and Validation (were solutions effective?)

  • Reviewed by PM/Supervisor (Name and Signature)

  • Approved by Practice Safety Leader (Name and Signature)


  • Positive Comments

  • Conclusion/Why the Questionable Items Occurred?

  • Feedback Session Conducted by (Name and Signature)

  • Name of Observee's Supervisor (Name and Signature)

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.