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Observer Name*
Date of Observation*
Date Format: MM slash DD slash YYYY
Time of Observation*

: Hour

Minute
Location*
Site*
Site*
Site*
Area*
Safety Topic*
- Safe Operation
- PPE
- Housekeeping
- Unsafe Operation
- Ergonomics
- Fall Hazard
- Respirator Use
- Chemical Exposure
- Unsafe Act
- General Communication
- Other
Risk Ratings
Severity*
- Critical
- Major
- Moderate
- Minor
Severity = the potential degree of harm presented by behaviors or conditions. From the categories below, select the highest potential severity that could have resulted.
- Critical = Death or permanent total disability AND/OR > $1 million property or equipment damage
- Major = Permanent partial disability AND/OR lost time injury greater than 1 month AND/OR $100,000 to $1 million property or equipment damage
- Moderate = Lost-time injury or injury resulting in a work restriction AND/OR $1,000 to $100,000 property or equipment damage
- Minor = Minor injury or first aid treatment only AND/OR readily repairable property or equipment damage of less than $1,000
Exposure*
- Frequent
- Occasional
- Seldom
- Rare
Exposure = the frequency of the hazards or risks occurring. Choose from the following
- Frequent = exposed to the hazard or risk 1 or more times per day
- Occasional = exposed to the hazard less than daily, but 1 or more times per week
- Seldom = exposed to the hazard less than weekly, but 1 or more times per month
- Rare = exposed to the hazard less than monthly, but 1 or more times every 3 months
Priority*
- Extreme
- High
- Medium
- Low
Priority = Effect of hazard or risk on (1) current work and (2) urgency of corrective actions
- Extreme = Work stopped immediately as imminent danger is present. Appropriate VP and Safety Professional notified immediately along with CEO and VP of HR, Safety and Health. Immediate corrective actions required. Work cannot continue until situation is deemed safe by above-listed personnel
- High = Work stopped immediately. Appropriate field supervisor / production manager and Safety Professional notified immediately. Work cannot continue until situation is deemed safe by above-listed personnel. Immediate corrective actions required.
- Medium = Work may proceed with caution when it is deemed safe by the local supervisor. Corrective actions are necessary but can be scheduled to occur in the future.
- Low = Work may proceed, but would benefit from corrective actions.
View all Risk Rating Descriptions
Ttl
Respirator User Name*
Comments*
Photos of issue
Drop files here or

Accepted file types: jpg, gif, png, jpeg, jpg.
You may upload 4 images at a time. Each image needs to be less than 10MB.
Status*
- Completed
- Needs Attention
Corrective Action*
Corrective Action
Follow Up Actions
Completion Date*
Date Format: MM slash DD slash YYYY
Individual to be Notified

Enter email of individual that needs to be notified.

Risk Ratings