Safety Observation
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contractor
Area
Please Select
North
Central
South
Mountain
Number of People Observed
General Foreman
GF Present?
Please Select
Yes
No
Foreman
Address/Location
Line Index and Structure
Type of Work
Length of Observation
Announced or Unannounced?
Please Select
Announced
Unannounced
Was an All Stop Called?
Please Select
Yes
No
Notes
PPE
Rows
Meet
Not Meet
Not Observed
Not Applicable
Eye Protection
1
2
3
4
Foot Protection
5
6
7
8
Hand Protection
9
10
11
12
No Jewelry
13
14
15
16
Hearing Protection
17
18
19
20
Appropriate Clothing
21
22
23
24
Head Protection
25
26
27
28
Notes
PJB
Rows
Meet
Not Meet
Not Observed
Not Applicable
Site Specific PJB
29
30
31
32
Circuit ID
33
34
35
36
Emergency Facility
37
38
39
40
Employee in Charge
41
42
43
44
PJB Participation
45
46
47
48
Hostile Situations
49
50
51
52
Chip Area Defined
53
54
55
56
Job Scope
57
58
59
60
Hazards/Mitigation
61
62
63
64
Voltage and MAD
65
66
67
68
Tasks Identified
69
70
71
72
Address
73
74
75
76
Environmental Assessment
77
78
79
80
Notes
MAD, LOF, and Fall Protection
Rows
Meet
Not Meet
Not Observed
Not Applicable
Adheres to MAD (CVR)
81
82
83
84
Proper Fell Zone (CVR)
85
86
87
88
Proper Drop Zone (CVR)
89
90
91
92
Proper Fall Protection (CVR)
93
94
95
96
Performer Secured Appropriately (CVR)
97
98
99
100
Fall Protection/Climbing Gear Condition (CVR)
101
102
103
104
Aerial Rescue Gear Ready
105
106
107
108
Notes
Chipper
Rows
Meet
Not Meet
Not Observed
Not Applicable
Condition of Chipper
109
110
111
112
Safety Decals
113
114
115
116
Guards
117
118
119
120
Chipper Area Free of Ropes and Debris
121
122
123
124
Chipper Not Running Unattended
125
126
127
128
Proper Hand Protection
129
130
131
132
Appropriate Work Position
133
134
135
136
Notes
Aerial Lifts and Trucks
Rows
Meet
Not Meet
Not Observed
Not Applicable
Aerial Lift Positioning
137
138
139
140
Aerial Lift Condition
141
142
143
144
Specialized Safety Device
145
146
147
148
Seatbelts Worn
149
150
151
152
Towing
153
154
155
156
Outriggers Engaged
157
158
159
160
Wheels Chocked
161
162
163
164
Notes
Work Zone and Traffic Control
Rows
Meet
Not Meet
Not Observed
Not Applicable
Traffic Control
165
166
167
168
Public and Crew Protected
169
170
171
172
Proper Work Zone
173
174
175
176
Notes
Tools
Rows
Meet
Not Meet
Not Observed
Not Applicable
Tools Maintained
177
178
179
180
Tools Properly Utilized
181
182
183
184
Notes
Type a question
Rows
Meet
Not Meet
Not Observed
Not Applicable
Electrical Hazards Identified
185
186
187
188
Electrical Hazards Mitigated
189
190
191
192
Lines Grounded When Necessary (CVR)
193
194
195
196
Notes
Job-Site
Rows
Meet
Not Meet
Not Observed
Not Applicable
Managed in an Appropriate Manner
197
198
199
200
Notes
Housekeeping, Storage, etc.
Rows
Meet
Not Meet
Not Observed
Not Applicable
First Aid
201
202
203
204
Fire Extinguisher
205
206
207
208
Spill Kit
209
210
211
212
Containers Maintained & Secured
213
214
215
216
General Housekeeping
217
218
219
220
Notes
Herbicides
Rows
Meet
Not Meet
Not Observed
Not Applicable
Product Handling
221
222
223
224
Correct Application Techniques
225
226
227
228
Closed Loop System Utilized
229
230
231
232
Stumps Treated Appropriately
233
234
235
236
SDS' Accessible
237
238
239
240
Proper Labeling
241
242
243
244
Notes
Communication
Rows
Meet
Not Meet
Not Observed
Not Applicable
Zone Communications Utilized (CVR)
245
246
247
248
Confirmation of De-energizing (CVR)
249
250
251
252
Pre-Flight Communication/Spotter Check
253
254
255
256
Verify Isolating & Grounding Lines (CVR)
257
258
259
260
Equipment Operator & Support Person/Spotter
261
262
263
264
Trimmer & Spotter
265
266
267
268
Notes
Terrain Hazards and Environmental
Rows
Meet
Not Meet
Not Observed
Not Applicable
Reference Documents or Other Available Tools Utilized?
269
270
271
272
Environmental Concerns/Conditions Identified, Documented and Mitigated
273
274
275
276
Structures and Features Identified, Documented and Mitigated
277
278
279
280
Hazardous Conditions as it Relates to Topography Identified, Documented and Mitigated Control Measures Being Utilized to Mitigate Terrain Hazards?
281
282
283
284
Notes
Feedback Given?
Follow Up Required?
Positive Observations
Coaching Moments
Notes
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