Name *

First Name

Last Name

Date *

MM

DD

YYYY

Time *

Hour

Minute

Second

AM PM

Body Position / Ergonomics

Falling

Struck By / Line of Fire

Foot Placement

Caught In / Crush

Hand Placement

Strike Against

Lifting / Pushing

Contacting Energy

Personal Protective Equipment (PPE)

Hard Hat

Hearing Protection

Gloves

Steel Toes / Foot

Safety Glasses

Respiratory Protection

Fall Protection

PFD

Face Shield

FRC

Tools & Equipment

Proper Tool/Select

Stairs / Ladders

Proper Use

Electric / Cords

Condition

Rigging/Sling/Shackle

Hand Tool

Forklift / Crane

Power Tool

Personnel Basket

Guards

Pressure Washer

Hose/Valve/Coupling

Lockout / Tagout

Welding / Hot Work

Barricades/Handrail

Conditions – Work Area

Slip / Trip Hazard

Weather / Lightning

Open Holes

Lighting/Ventilation

House Keeping

Tool Storage

Walkways / Aisles

Shielding/Barricade

Oil / Chemical Spill

Trash / Waste

Behaviors - Skills

Short Cuts/ Hurry

Knowledge/Experience

Fatigue

Communication

Attitude

Awareness

Barriers to Safe Behavior

Untrained

Frustration

Convenience

Fatigue

Policy / Procedure

Personal Factor

Communication

Line of Fire

Complacency

Personal Choice

Disagrees on Practice

Rushing

Facilities

Equipment

Hazard Recognition

Culture