Title Page
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Project Name
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Project #
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Location
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Date and Time
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Observer Name
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Observee Name
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Task Observed
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Description of Task Observed and Background Information
PERSONAL PROTECTIVE EQUIPMENT
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1. Hearing Protection (e.g., Ear Plugs)
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2. Head Protection (e.g., Hard Hat)
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3. ANSI Rated Eye Protection (e.g., Safety Glasses)
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4. Hand Protection (e.g., Kevlar Gloves)
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5. Foot Protection (e.g., Safety Shoes)
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6. Respiratory Protection
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7. Fall Protection Inspected (e.g., Harness)
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8. ANSI Rated Reflective Vest/High Visibility Clothing
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9. Other ( Specify)
FIRST AID & CPR
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At Minimum, One Employee Per Shift Currently Certified in First Aid & CPR
TRAILER SAFETY EQUIPMENT
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Are the Trailer Wheels Chalked?
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AED Defibrillator Location is Marked, Readily Accessible and Inspected Monthly
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Eye Wash Station Location is Marked, Readily Accessible and and Inspected Monthly
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First Aid Kit Location is Marked, Readily Accessible and and Inspected Monthly
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Fire Extinguisher Location is Marked, Readily Accessible and Monthly Inspection is current
BODY USE AND POSITIONING
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1. Correct Body Positioning When Lifting/Pushing/Pulling
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2. Pinch Points Identified Body/Appendages Clear
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3. 3-Points of Contact when ascending and descending ladders
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4. Other (Specify)
WORK ENVIRONMENT
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1. Work/Walk Surface Are Free of Obstructions (e.g., Tripping Hazards)
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2. Housekeeping/Storage
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3. Defined and Secured (e.g., warning devices, barricades, cones, flags)
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4. Lift Area / Drop Zone is Identified and Barricaded
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6. Proper Storage & Labeling /Disposal of Sample & Waste Materials
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7. Cylinders Stored Upright, Secured, & Caps in Place
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9. Other (Specify)
OPERATING PROCEDURES
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1. HASP is readily available and has been signed
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2. JSA Reviewed & Signed
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4. Hazard Assessment - Hazard Hunt
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5. Other (Specify)
TOOLS/EQUIPMENT
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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
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1. Employee has been trained / certified to operate motorized equipment
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What is the equipment type?
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2.Employee has been trained and is current on fall protection types and use.
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What is the name of the employee(s) and date(s) of most current Fall Protection training?
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3. Ladders are Inspected & Set Up Correctly
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6. Other (Specify)
AT-RISK OBSERVATIONS/ROOT CAUSE ANALYSIS
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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
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At-Risk Observation #
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Root Cause Analysis #
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Solution(s) To Prevent Potential Incident from Occuring
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Person Responsible
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Agreed Due Date
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Date Completed
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Results of Verification (were solutions done?) and Validation (were solutions effective?)
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Reviewed by PM/Supervisor (Name and Signature)
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Approved by Practice Safety Leader (Name and Signature)
SIGN OFF
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Positive Comments
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Conclusion/Why the Questionable Items Occurred?
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Feedback Session Conducted by (Name and Signature)
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Name of Observee's Supervisor (Name and Signature)
