LOSS PREVENTION OBSERVATION FORM

Observer Name Observer Title Project/Project Number

Date______________ Project Type/Task Observed

Time_____ AM PM
Background Information

List Critical Work Procedures

List Issue /Items Requiring Corrective Action

Root Cause Analysis

1. Employee lacks the skill or knowledge to carry out duties
2. Procedures, work standard, or expectations were not communicated
3. Procedure or work standards were not developed or were inadequate
4. Equipment, systems or tools were inadequate
5. Employee chose not to take the time or put forth the effort to do the job properly
6. Supervisor did not require the employee to follow the standard procedure
7. Employee doesn’t see any advantage to doing the job to standard
8. Uncontrollable

Criterion # RCA # Corrective Action Responsible Due Closure Date

Identified Individual Date

Results of Corrective Action

Reviewed by Date Reviewed by Date

1
 Environmental Operations

PRE-TASK PREPARATION Correct Questionable Comments

1 Health & Safety Plan /MSDS on site
2 Employee familiar/trained on task
3 OSHA-required training/medical
surveillance
4 Utility mark out/check performed
5 Traffic hazard addressed/work area
marked
6 Walking/working surfaces free of
hazards
7 Tailgate safety meeting performed
8 Impact on nearby residence/business
evaluated
9 Communicates intentions to other
personnel
10 Knowledge of emergency procedures
11 Distance between equipment and
power lines
12 Personal protective equipment
13

2
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