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Code Personal Protective Equipment ‘Soe [Gvmers) [Work Conditions and Housekeeping | Sue [Gowns Hard hat ye and fae protection, footwear | L1_| Li_| [Work areas clean: ee of slp or tip hazards |__|) Hearing protection [1] [Weather conditions oo Respiratory protection’ Ar monor CTO] [Adequate ighting oto Proocive cthing loves CE] [Proper permits & tak oulag oat oo Fall protection TC] ] Sens, bamcades,guaes, ais, saey | | 4 Appropriate working aire TT | equipment Totals Fire and emergency equipment o}o Body Positon/Body Mechanics Sa [Csee rea Clear of ine of fre™ (| 0 | [Vehicles and Mobile Equipment Sae_[Ceca Clear pinch pots, sharp edges end | 1, | pq | [Condon nd Maintenance o1o hot suraces Alyce motion safety oyo Eyes on path arwork TI] ] [Wearng seat bets oto ‘Ascendng/Descendngistars, steps | | Useotsalety equipment oo or fied adders Tae Body mechanics when iting reaching, | | 7) | (ob Specific Safely Procedures [Sie | Cains pulling, pushing, cacying fom at Clit |. | n Acton to protect otha oto ‘Adequate personne or job o yo rovais|{ | Totals Tools and Equipment Se [Ca Prope selection and use of ols oto Equipment ce-energzed oto Condon f fois cP or Location of fois oo Totals COMMENTS:@ Safety Observation Form Feedback Comments Behavior (every observation) LL]. What: (behavior observed) (every observation) Why: (feedback from Observee)(atisk) Barer: (atsisk) o.0 Solution: (atsisk) Behavior #: (every observation) 0 What: (behavior observed) (every observation) Why: (feedback from Observee)(al-risk) carer avis) 1.) Solution: (atsisk) Quality Rati i% Reviewer Di: DATE: OBSERVER ID M00 O10 WORK GROUP: LOCATION: © SELFOBS © Short Term Empl © Near Miss ‘© Observee BBSP Trained © High Activity HAZARDID: REQUESTED OBS: — SIDEISIDE OBS: TASK: (every observation) At A Body Positions Sle Rk | PPE Sale Fk 101 Pinch Poms CO |Z Head oo 402 LineofFire = Q O]202Heaing §=§ OO 103 Ascending’ ==» | 203 Fest oo Descending 204 Fal Protection QO © 104 EyesonPat’ =O O|205 eyesraxe OO Work 206 Hands = SOO 1.05 BendingiLiting CO) © |2.07 PFDMork Vest O 208 Respirator =O O Procedures! Operations Diving 301 JooPianing §=§O Olaoramugn OO 3.02 Bariers/Signs =O OQ] _ in Steering 303 Crane Operations CQ O| 402 Keep Your OO 3.04 TeolsEqument QO] EyesMoving 405 Heicopter = CO |403 Make gure OO peraons They See You 3.06 LockoutTagout © © | 4.04 Get the oo 307 Housekeeping OO] — BigPetue 308 Boat Operations. CO |405 Leave Yousel O © 3.09 Rigging OO} Anout Ergonomics Other 501 Work Sutaves =O O|601 Other oo 5.02 Screen oo 503 ChairHeigny = OO Backrest 5.04 Keyboard Position QO 5.05 Task Management © Type: O hry ness O Environmental ‘© Property Loss or Damage Motor Vehicle Near Miss Description: Hazard Description Solution to Hazard:[crop competep carom company Man — Ml] [IBD vorcrocesemenmaso-ranenmestancremeereion ll + migoman | [agate fC Cae cet oe ait bel ‘ontmmrypmies | | 7 commcsnrasnne | | 1 serene o Sat Ope Ono as 0 ions | eam ama Narr LAND Comoany Peming Aus — CO [ereeeetesce Yat]: wetense is | somone | [tec | |RSS ay rere 1D | zroterstenate 1D] secret o TWARTARER TOERTION RUSTED) , ew Seen Onee es Scone DY] estou Yo sa sess o inoenon se ae 1 | tess ehees ee I 1 seem D Je samieemeesnig || ae om o ‘COMPANY TACTNITY (AUDITED) Bases S|» enaryoan, | Co | mrt Sapo patty steed, Mago |e cetatotonatn | O | sarwate o Sewanee ‘temeemm, | S|: eopeimrmene | © Jacratenrmnt |) a“ PEST |S fo apeeneeangae | | mon o Sere ee | nme | PE o eh fetes Cram roncan tye — Ouoww _ Ovoweamoe | |[soummue | O)/*temmm™ (0 o Stomeaer Sinners Orth Crepe © ses oe Vmerwmpen |S feces | 0 Stereum" Sgn” stan, S catays:Sprcster © indserai teen © Oar Once S Stat Susgon exteoamnteam | fie nevatcnmntocnmie | o Scncreone) Sime Sra” Otmunsean | [teomeme= |g femmes, | o o Strom” Siemete Grown Stowe creer || Stuer Stuer” Gaiman Steamer | || tuaaasnan | O a Sherwests Ohiaee — Otatmny Over eee |e [aati |ES cd Stickowm Ouse Ommay” Owen deste || Segre = jase a a Other 12 wrcemnecomiy | | s esresyonacres | O Q Erna a - [ROTE-Y Fatonap AGN eGo NOU our Rope = rementere rr a sates | ae || awmoumonm | O ps = Saeco | Frame Heats || al meme To treme [Ofrewewerene | 0 [2s iy ee Ace vadcnttgens screremewe | © [Eten — fl Stren earretetaen| e 1O| sma | O — smomtsavergman | | ornare moat 1D | + em n a 4 tateratatnae |) tor | erent io semen INES [OL cnsensien | | tamer | immanent |Tr 7 Tr 7 Use ius o bck nk pen oni ‘Pr clean UPPERCASE ‘eosin the wren boxes Fain answer bubble compre. 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