Clone of TS STAR Form e-2017 Form Template

Employee ID *

Branch *

Branch Observed

Date *

- Month - Day Year

Observation Occurred at:

Vertical Market

Task Conducted

Personal Protective Equipment

Head Protection

Safe Unsafe N/A

Eyes and Face

Safe Unsafe N/A

Hearing Protection

Safe Unsafe N/A

Respiratory Protection

Safe Unsafe N/A

Arms and Hands

Safe Unsafe N/A

Trunk/Torso

Safe Unsafe N/A

Legs and Feet

Safe Unsafe N/A

Tools & Equipment

Correct for the Task

Safe Unsafe N/A

Used Correctly

Safe Unsafe N/A

In Safe Operating Condition

Safe Unsafe N/A

Procedures/General

Employee(s) familiar with the SOP's for the Task?

Safe Unsafe N/A

SOP's Being Followed?

Safe Unsafe N/A

TSOSEC Form Completed?

Safe Unsafe N/A

Area free from clutter, trash, debris etc?

Safe Unsafe N/A

Bonding and Grounding in place and verified?

Safe Unsafe N/A

Employee(s) wearing appropriate/required uniform?

Safe Unsafe N/A

Fall Protection utilized

Safe Unsafe N/A

Employee's Clean Shaven?

Safe Unsafe N/A

Emergency Equipment

Fire Extinguishers available, appropriate, inspected, and within dates?

Safe Unsafe N/A

First Aid Kits available and appropriate?

Safe Unsafe N/A

Eye Wash (plumbed or bottled) immediately available, inspected, and within dates?

Safe Unsafe N/A

Vehicle Safety equipment available?

Safe Unsafe N/A

Emergency Communication method available/appropriate?

Safe Unsafe N/A

Body Position

Repetitive Motions?

Safe Unsafe N/A

Awkward Positions/Static Postures?

Safe Unsafe N/A

Proper Lifting Techniques?

Safe Unsafe N/A

Body not in Line of Fire?

Safe Unsafe N/A

3 Points of Contact Maintained?

Safe Unsafe N/A

Follow Up Communications

Discussion with Observed and Positive behaviors discussed?

Yes No N/A

Issues/questionable behaviors discussed with observed?

Yes No N/A

Issues Corrected on-site?

Yes No N/A

Additional measures or corrections required from Management?

Yes No N/A

Comments to clarify issues:

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Clone of TS STAR Form e-2017

TS STAR Form e-2016