2. HSEQ OBSERVATION / INTERVENTION

4. Date and Time of Observation
   Date and Time of Observation

   Date and Time of Observation
6. Site / Location
8. Name of Observer (Optional)
10. Department
12. Project
14. Description of Observation
16. Was a Work Order Submitted?

    1. Yes
    2. No
18. Behavior Checklist
20. Critical Safety Behaviors: Safe

    SAFE

    1. Eyes on path
    2. Line of fire
    3. Use of tools and equipment
    4. Pinch points
    5. 3-point contact
    6. Communication
    7. Housekeeping
    8. Pre-job planning
    9. Assistance needed/used
    10. Walking/working surfaces
    11. Eyes on task
    12. Hot-work preparation
    13. Manual handling
    14. Lock-out/Tag-out system/energy isolation
    15. Use of barriers and warnings
    16. Conformance to rules/procedures/policies
    17. Immediate reporting of injury
    18. Correct PPE worn for task
    19. Head protection
    20. Eye/face protection
    21. Respiratory protection
    22. Protective clothing
    23. Hand/arm protection
    24. Feet/ankle protection
    25. Hearing protection
    26. Working at heights PPE
21. Critical Safety Behaviors: At Risk

    AT RISK

    1. Eyes on path
    2. Line of fire
    3. Use of tools and equipment
    4. Pinch points
    5. 3-point contact
    6. Communication
    7. Housekeeping
    8. Pre-job planning
    9. Assistance needed/used
    10. Walking/working surfaces
    11. Eyes on task
    12. Hot-work preparation
    13. Manual handling
    14. Lock-out/tag-out system/energy isolation
    15. Use of barriers and warnings
    16. Conformance to rules/procedures/policies
    17. Immediate reporting of injury
    18. Correct PPE worn for task
    19. Head protection
    20. Eye/face protection
    21. Respiratory protection
    22. Protective clothing
    23. Hand/arm protection
    24. Feet/ankle protection
    25. Hearing protection
    26. Working at heights PPE
23. Conditions Checklist

    Check any hazardous conditions observed

25. Unsafe Conditions

    AT RISK

    1. Warning system inadequate
    2. Defective Tools/Equipment/Materials
    3. Inadequate guards and barriers
    4. Fire and explosion hazard
    5. Extreme weather conditions
    6. Inadequate layout of workplace
    7. Poor housekeeping
    8. Correct protective equipment not available
    9. Slippery or uneven surface
    10. Misplaced/loose objects at risk to fall
    11. 3rd party activities
    12. Maintenance
27. Environmental Observation

    AT RISK

    1. Spill/release to air, sea, land potential
    2. Material storage inadequate
    3. Waste disposal inadequate
    4. Energy management inefficient
28. Quality Observation

    1. Procedures/work instruction issue
    2. Equipment/Material issue
    3. Certification issue
    4. Planning/scheduling ineffective
    5. Training/induction inadequate
    6. Improvement suggestion
30. Corrective/Immediate Action Taken
32. Further Action Required
34. Insert Pictures
36. Picture
38. Picture
40. HSE Observation Closed Out

    Comment

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