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| Observer Name | first last |
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| Date | 02/13/2024 |
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| Location | Ankeny |
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| Department | Department |
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| Shift | Second |
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| Upload a Picture Example | |
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| PERSONAL PROTECTIVE EQUIPMENT | |
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| PPE is adequate and worn correctly | Unsafe |
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| ERGONOMICS | |
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| Loading, bending over & twisting | Safe |
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| Overstretching, pulling & pushing | Safe |
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| SAFETY PROCEDURES | |
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| They are known and respected | Safe |
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| FLOOR, AISLES & WORK AREAS | |
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| Floor free of spills and without tripping hazards | Not Applicable |
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| SAFETY IN MACHINERY | |
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| Safety guards installed | Safe |
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| Interlocks are present, light curtains, emergency stops are working | Unsafe |
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| POWERTOOLS AND HANDTOOLS | |
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| They are in good conditions and they are adequate for the type of job | Not Applicable |
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| AT THE FIRE LINE | |
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| Trapping - pinching points & being hit by an object | Safe |
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| OTHER QUESTIONS | |
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| Task or work area observed | |
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| Describe the unsafe act or unsafe condition observed as well as the behavior observed, including the immediate countermeasures taken | |
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| If a follow up is required, describe the actions to be taken | |
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