Safety Gemba Walk Report Form
Please complete the Safety Gemba Walk Report Form to document your workplace safety walk, observations, and follow-up actions.
Walker's Name
*
First Name
Last Name
Date of Walk
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Area/Department Observed
*
Please Select
Production
Warehouse
Office
Maintenance
Shipping/Receiving
Other
Shift / Time of Walk
*
Please Select
Morning
Afternoon
Night
Other
Safety Focus / Observation Category
*
Please Select
Housekeeping
Equipment Safety
PPE Compliance
Ergonomics
Chemical Safety
Other
Specific Safety Observations
*
Hazards Identified (if any)
Immediate Corrective Actions Taken
Follow-Up Owner
First Name
Last Name
Priority / Status for Follow-Up
*
High - Immediate Action Required
Medium - Action Needed Soon
Low - Monitor or Schedule Later
Resolved
Submit Report
Should be Empty: