JOB SAFETY OBSERVATION FORM

Manager/ Supervisor_____________________ Unit/Line__________________________

Facility/Ship_____________________________ Date_____________________________
Department _____________________________ Time ____________________________
Description of observation (Unsafe Act):
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Description of observation (Unsafe Condition):
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Action(s) taken: (i.e. commended employee, corrected unsafe condition, etc.)
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Potential for Injury or Deficiencies noted: ________________________________________________________

Personal Protective Equipment Position Tools

_____Eyes & Face _____Struck by or against _____Correct tool for job?

_____Ears/Noise _____Caught between _____Proper Use
_____Hands/Glove _____Fall or Trip _____Guard complete
_____Feet _____Temperature ( ) Hot, ( ) Cold _____Tools aren't damaged
_____Respiratory/Mask _____Lifting _____Other 000000.
_____Other 0000000000. _____Other 0000000000.

Facilities Procedures Behaviors

_____Cleanliness/Housekeeping _____Written task procedures? _____Communicates?

_____Work area design _____Were they followed? _____Eye contact /hazard?
_____Floor Surfaces _____Are they adequate? _____Work pace (behind)?

0000000.. 00000000.
(Prateep Chumyen) (Umapron Nainaum)
Safety Coordinator Safety Officer