Safety Observation Report

Observation Type*

Safe

Unsafe

Near Miss

Job Name *

I prefer to remain anonymous

Name:

Date & Time:

Company/Employee Observed:

Specific Location:

Multi choice

Eye/Face PPE

Ladder Safety

Scaffolding

Hand/Arm PPE

Fall Protection

LO/TO

Head PPE

Barricading

MEWP

Foot PPE

Vehicle Safety

Tool for Job

Hearing PPE

Lift/Straining

Other

Other:

Description of Incident:

Corrective Actions Needed / Taken

Person Responsible to Correct:

Additional Information:

Perceived Reason or Cause of the Observation:

Belief

Training

Resources

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