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Acme Survey
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OBSERVATION REPORT
-
Step
1
of 3
Safe Acts observed and actions taken to encourage continued safe performance.
*
Unsafe Acts observed. Immediate Corrective Action. Actions to Prevent Recurrence
*
Next
REACTIONS OF PEOPLE
*
Adjusting Personal Protective Equipment
Changing Position
Rearranging Job
Stopping Job
Attaching Grounds
Performing Lockouts
PERSONAL PROTECTIVE EQUIPMENT
*
Head
Eyes and Face
Ears
Respiratory System
Arms and Hands
Trunk
Legs and Feet
POSITIONS OF PEOPLE (Injury causes)
*
Striking against objects
Struck by Objects
Caught in, On, or between Objects
Falling
Contacting Temperature Extremes
Inhaling
Absorbing
Swallowing
Overexertion
Repetitive Motions
Awkward Positions/Static Postures
TOOLS AND EQUIPMENT
*
Wrong for the job
Used Incorrectly
In Unsafe Condition
PROCEDURED AND ORDERLINESS
*
Procedures Inadequate
Procedures Not Known/Understood
Procedures Not followed
Orderliness Standards Inadequate
Orderliness Standards Not Known/ Understood
Orderliness Standards Not Followed
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Name
*
First
Last
Email
*
AREA/DEPT
SAFETY
SECURITY
RECOVERY
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