DEMO ACME FORM

Name

Email

Safe Acts observed and actions taken to encourage continued safe performance..

Unsafe Acts observed. Immediate Corrective Action. Actions to Prevent Recurrence

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

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