Planned Job Observation

P O I N T
plan observe inform note track
At Risk Human Behaviors Safe

□  Attention to work □
□  Communication □
□  Housekeeping behavior □
□  Job setup/sequence □
□  Using personal protection □
□  People's positions □
□  Following standards, processes and procedures □
□  Using tools and equipment □
□  Recognizing a change □
Working Conditions

□  Ambient conditions □
□  Condition of tools and equipment □
□  Housekeeping conditions □
□  Guards and barriers □
□  Workplace design □
Safety Management Tools

□  Use of safe work permit □

□  Use of safety device bypass □
□  Use of lockouts □
□  Isolation and zero energy □
Other

□  □
□  □
 Planned Job Observation Report
Company ________________________________________________ Site __________________________

Work Observed ____________________________________________________________________________

What was observed? What was said? Follow-up action:

(R/C) Reinforcement/Correction What is to be done?

( )

( )

( )

( )

( )

( )

( )

Any change in behavior during observation: □ Yes □ No

Completed by (print):_________________________________________________________________________ Date: _____________________________________________

Contractor/Sub-Contractor (print): _____________________________________________________________________________________________________________

(Name of Company observed)

Planned Job Observation Page 2 of 2

October 2006