Environment / Working Conditions Housekeeping SafeUnsafe Toxic Atmosphere SafeUnsafe Work Plans / ProceduresAvailable SafeUnsafe Condition of Tools & Equipment SafeUnsafe Hazard Warnings SafeUnsafe Safety Devices in Place SafeUnsafe Behaviours Using PPE SafeUnsafe Procedures Followed SafeUnsafe Communicating SafeUnsafe Proximity to Other Workers SafeUnsafe Work Pace SafeUnsafe Horseplay SafeUnsafe Focuson on Work Distraction SafeUnsafe Balance, Traction, Grip SafeUnsafe Pre-Task Planning / Permits SafeUnsafe Recognizing Change SafeUnsafe Body Mechanics Reaching / Extending SafeUnsafe Lifting / Bending SafeUnsafe Repetitive Motion SafeUnsafe Standing / Sitting SafeUnsafe Comfortable SafeUnsafe Line of Fire Body Position SafeUnsafe Energy Sources SafeUnsafe LockOut SafeUnsafe Guards Barriers SafeUnsafe Engineering Controls SafeUnsafe Workplace Design / Condition SafeUnsafe Congested Work Area SafeUnsafe Tools & Equipment Pre-Job Inspection SafeUnsafe Correct For Task SafeUnsafe Safe Use SafeUnsafe Employee Competency Check Knowledge / Trained / Certificate SafeUnsafe Skill / Experience SafeUnsafe Management / Supervisory Training / Coaching SafeUnsafe Worker / Supervisor Competency SafeUnsafe Procedures Available Adequate Understood SafeUnsafe Location Work Observed: What Was Observed? (optional) What Was Said? (R/C) Reinforcement / Correction (optional) Follow-up Action What Is To Be Done? (optional) Any change in behaviour during observation YESNO Observer Name (print) Date
