Employee Observed

Crew Observed

Observation Classification

Observation Category

Observation Description

Observation Status

Action Taken

Observation Reporting

Risk Rating


Photo Description

Site Contact Type

Site Contact Name

Observer Name & Signature
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.