HAZZARD ID / NEAR MISS CARD HAZZARD ID / NEAR MISS CARD

Date: _________________________ Location: ________________________ Date: _________________________ Location: ________________________

Job#: _________________________ Time: ___________________________ Job#: _________________________ Time: ___________________________

DEFINITIONS DEFINITIONS
NEAR MISS – Any event, which under slightly different circumstances, may have NEAR MISS – Any event, which under slightly different circumstances, may have
resulted in injury, ill health, or damage / loss of property, materials, or environment. resulted in injury, ill health, or damage / loss of property, materials, or environment.

HAZARD – Source or situation with a potential for harm in terms of injury, ill health, HAZARD – Source or situation with a potential for harm in terms of injury, ill health,
damage to property, damage to workplace or environment. damage to property, damage to workplace or environment.

TYPE: TYPE:
HAZARD ID HAZARD ID
NEAR MISS NEAR MISS
DESCRIPTION: DESCRIPTION:

POSSIBLE CONSEQUENCES: POSSIBLE CONSEQUENCES:

IMMEDIATE CORRECTIVE ACTIONS: IMMEDIATE CORRECTIVE ACTIONS:

FOLLOW UP ACTION FOLLOW UP ACTION

Reported By: ___________________________ Supervisor Signature: __________________ Reported By: ___________________________ Supervisor Signature: __________________
 OBSERVATION CARD OBSERVATION CARD
Date: _________________________ Location: ________________________ Date: _________________________ Location: ________________________

Job#: _________________________ Time: ____________________________ Job#: _________________________ Time: ____________________________

DEFINITIONS
SAFE BEHAVIOR OBSERVATION – Performing task in a safe manner, doing something that
benefits the safety of others (Worker picking up garbage that’s not theirs, maintain 3-point
contact while using ladders ladder, encouraging a positive safety culture on site).
AT RISK OBSERVATION – Condition on site or actions of people that could pose a health and
safety risk to themselves or others.
DEFINITIONS
SAFE BEHAVIOR OBSERVATION – Performing task in a safe manner, doing something that
benefits the safety of others (Worker picking up garbage that’s not theirs, maintain 3-point
contact while using ladders ladder, encouraging a positive safety culture on site).
AT RISK OBSERVATION – Condition on site or actions of people that could pose a health and
safety risk to themselves or others.

TYPE OF OBSERVATION (SELECT ONE) TYPE OF OBSERVATION (SELECT ONE)

SAFE BEHAVIOR OBSERVATION SAFE BEHAVIOR OBSERVATION
AT RISK OBSERVATION AT RISK OBSERVATION

OBSERVATION DESCRIPTION: OBSERVATION DESCRIPTION:

POSSIBLE CONSEQUENCE: POSSIBLE CONSEQUENCE:

CORRECTIVE ACTION TAKEN: CORRECTIVE ACTION TAKEN:

Reported By: _______________________ Supervisor Signature: ______________________ Reported By: _______________________ Supervisor Signature: ______________________