Safety Entry Form

Observer Name(Required)

First Last

Date(Required)

Location(Required)

Department

Shift(Required)

PPE is adequate and worn correctly(Required)

Loading, bending over & twisting(Required)

Overstretching, pulling & pushing(Required)

They are known and respected(Required)

Floor free of spills and without tripping hazards(Required)

Safety guards installed(Required)

Interlocks are present, light curtains, emergency stops are working(Required)

They are in good conditions and they are adequate for the type of job(Required)

Trapping - pinching points & being hit by an object(Required)