Test Form

Instructions: Introduce yourself to the other person and announce your observation to the worker. Observe for 2-3 minutes – focus on the safety practices. Check safes and describe concerns. Choose 2-3 important practices to discuss briefly (include no more than 1-2 concerns). Listen to response and thank the worker for the observation. Write down something they can work on to be safer and let them know of your concerns and/or things done well.

Task Name Safe Feedback Concern Comments
Body mechanics when lifting or carrying

– lift with legs not back, get help with large awkward items

Keep eyes on work

– watch hands and body parts while engaged in task

Use tools and equipment as designed

– right tool for the right job, guards in place, wooden handles in good shape

Work area clear & organized

– tools, equipment & material stacked neatly, prompt removal of debris and/or spills

Signs, barricades and/or flaggers in place

– proper barricade tape color and contact information posted, flaggers visible

Using Properly Maintained PPE

- hearing protection, hardhat, footwear, safety glasses, silica protection, gloves, Kevlar sleeves, etc.

Access & Egress not blocked

– clear pathway to exits and stair