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Port of Galveston 200th Anniversary
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Safety Observation Card Form
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Safety Observation Card Form
Safety Observation Card Form
HSEQ Safety Card
HSEQ observation / Intervention
Date of Observation
MM slash DD slash YYYY
Time of Observation
Hours
:
Minutes
AM
PM
AM/PM
Site / Location
Name of Observer (Optional)
First
Last
Department
Project
Description of Observation
(Required)
Was A Work Order Submitted?
Yes
No
Critical Safety Behaviors: Safe
Eyes on path
Line of fire
Use of tools and equipment
Pinch points
3-point contact
Communication
Housekeeping
Pre-job planning
Assistance needed/used
Walking/working surfaces
Eyes on task
Hot-work preparation
Manual handling
Lock-out/Tag-out system/energy isolation
Use of barriers and warnings
Conformance to rules/procedures/policies
Immediate reporting of injury
Correct PPE worn for task
Head protection
Eye/face protection
Respiratory protection
Protective clothing
Hand/arm protection
Feet/ankle protection
Hearing protection
Working at heights PPE
Critical Safety Behaviors: At Risk
Eyes on path
Line of fire
Use of tools and equipment
Pinch points
3-point contact
Communication
Housekeeping
Pre-job planning
Assistance needed/used
Walking/working surfaces
Eyes on task
Hot-work preparation
Manual handling
Lock-out/Tag-out system/energy isolation
Use of barriers and warnings
Conformance to rules/procedures/policies
Immediate reporting of injury
Correct PPE worn for task
Head protection
Eye/face protection
Respiratory protection
Protective clothing
Hand/arm protection
Feet/ankle protection
Hearing protection
Working at heights PPE
Conditions Checklist
Check any hazardous conditions observed
Unsafe Conditions: At Risk
Warning system inadequate
Defective Tools/Equipment/Materials
Inadequate guards and barriers
Fire and explosion hazard
Extreme weather conditions
Inadequate layout of workplace
Poor housekeeping
Correct protective equipment not available
Slippery or uneven surface
Misplaced/loose objects at risk to fall
3rd party activities
Maintenance
Environmental Observation: At Risk
Spill/release to air, sea, land potential
Material storage inadequate
Waste disposal inadequate
Energy management inefficient
Quality Observation
Procedures/work instruction issue
Equipment/Material issue
Certification issue
Planning/scheduling ineffective
Training/induction inadequate
Improvement suggestion
Corrective/Immediate Action Taken
Further Action Required
File
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Pictures
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Pictures
Max. file size: 100 MB.
HSE Observation Closed Out
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