Safety Observation
Date
-
Month
-
Day
Year
Date
Contractor
Area
North
Central
South
Mountain
Number of People Observed
General Foreman
GF Present?
Yes
No
Foreman
Address/Location
Line Index and Structure
Type of Work
Length of Observation
Announced or Unannounced?
Announced
Unannounced
Was an All Stop Called?
Yes
No
Notes
PPE
Meet
Not Meet
Not Observed
Not Applicable
Eye Protection
Foot Protection
Hand Protection
No Jewelry
Hearing Protection
Appropriate Clothing
Head Protection
Notes
PJB
Meet
Not Meet
Not Observed
Not Applicable
Site Specific PJB
Circuit ID
Emergency Facility
Employee in Charge
PJB Participation
Hostile Situations
Chip Area Defined
Job Scope
Hazards/Mitigation
Voltage and MAD
Tasks Identified
Address
Environmental Assessment
Notes
MAD, LOF, and Fall Protection
Meet
Not Meet
Not Observed
Not Applicable
Adheres to MAD (CVR)
Proper Fell Zone (CVR)
Proper Drop Zone (CVR)
Proper Fall Protection (CVR)
Performer Secured Appropriately (CVR)
Fall Protection/Climbing Gear Condition (CVR)
Aerial Rescue Gear Ready
Notes
Chipper
Meet
Not Meet
Not Observed
Not Applicable
Condition of Chipper
Safety Decals
Guards
Chipper Area Free of Ropes and Debris
Chipper Not Running Unattended
Proper Hand Protection
Appropriate Work Position
Notes
Aerial Lifts and Trucks
Meet
Not Meet
Not Observed
Not Applicable
Aerial Lift Positioning
Aerial Lift Condition
Specialized Safety Device
Seatbelts Worn
Towing
Outriggers Engaged
Wheels Chocked
Notes
Work Zone and Traffic Control
Meet
Not Meet
Not Observed
Not Applicable
Traffic Control
Public and Crew Protected
Proper Work Zone
Notes
Tools
Meet
Not Meet
Not Observed
Not Applicable
Tools Maintained
Tools Properly Utilized
Notes
Type a question
Meet
Not Meet
Not Observed
Not Applicable
Electrical Hazards Identified
Electrical Hazards Mitigated
Lines Grounded When Necessary (CVR)
Notes
Job-Site
Meet
Not Meet
Not Observed
Not Applicable
Managed in an Appropriate Manner
Notes
Housekeeping, Storage, etc.
Meet
Not Meet
Not Observed
Not Applicable
First Aid
Fire Extinguisher
Spill Kit
Containers Maintained & Secured
General Housekeeping
Notes
Herbicides
Meet
Not Meet
Not Observed
Not Applicable
Product Handling
Correct Application Techniques
Closed Loop System Utilized
Stumps Treated Appropriately
SDS' Accessible
Proper Labeling
Notes
Communication
Meet
Not Meet
Not Observed
Not Applicable
Zone Communications Utilized (CVR)
Confirmation of De-energizing (CVR)
Pre-Flight Communication/Spotter Check
Verify Isolating & Grounding Lines (CVR)
Equipment Operator & Support Person/Spotter
Trimmer & Spotter
Notes
Terrain Hazards and Environmental
Meet
Not Meet
Not Observed
Not Applicable
Reference Documents or Other Available Tools Utilized?
Environmental Concerns/Conditions Identified, Documented and Mitigated
Structures and Features Identified, Documented and Mitigated
Hazardous Conditions as it Relates to Topography Identified, Documented and Mitigated Control Measures Being Utilized to Mitigate Terrain Hazards?
Notes
Feedback Given?
Follow Up Required?
Positive Observations
Coaching Moments
Notes
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