Safety Observation Form

Date of Report:

MM slash DD slash YYYY

Time of Incident/Observation:

Hours

:

Minutes

AM/PM

Location/Job Site:

Type of Safety Issue (Check One):

Unsafe Working Conditions

Equipment Malfunction

Lack of PPE Compliance

Housekeeping Issue

Fall Hazard

Electrical Hazard

Good Catch

Other:

Reported By (Name & Position):

Describe the Safety Concern:

Photo Evidence Attached?

Accepted file types: jpg, jpeg, png, gif.

Immediate Action Taken (If Any)

Stopped Work

Reported to Supervisor

Placed Warning Sign/Barrier

Other:

Recommended Corrective Action:

Supervisor Notified?

Yes

No

Name of Supervisor Notified:

Follow-Up Required?

Yes

No

Target Resolution Date:

MM slash DD slash YYYY