SafetyCapture®

Automated Data Capture Solution

Sample Forms

1-800-722-6876 www.scantron.com © 2019 Scantron Corporation. All rights reserved.

Section 1:SafetyCapture onDemand Sample Forms

TampaDallasHoustonMinneapolis

Safety Observation Form

AtlantaPhoenixSan DiegoNew York

OBSERVERID Number

First Name

Last Name

SITE / LOCATION (Mark only one)

DATE

IndividualGroup

NUMBEROBSERVED

SHIFT(Mark only one)

DaysNightsSwing

StaffCraftVisitorSubcontractorOther

OBSERVER’S DEPARTMENT(Mark only one)

WORKER / WORKGROUP OBSERVED(Mark all that apply)

StaffMaintenanceWarehouseOperatorMachinist

BoilermakerCarpenterElectricianLaborerOther

Month Day Year

(Mark only one)1.0 Personal Protective Equipment

Eye / Face ProtectionHands ProtectionHead Protection

SAFE At-Risk1.11.21.3

2.0 Body Use and PositionWalkingClimbingLifting

2.12.22.3

(Mark only one)3.0 Workplace Conditions

LightingSurfaceHot Surface

SAFE At-Risk3.13.23.3

4.0 Transportation Cell Phone UseLightsBackup Alarm

4.14.24.3

CATEGORY ID

COMMENTS (clip)

CATEGORY ID

COMMENTS (KFI)

Print clearly inUPPERCASE letters.

Correct Mark:

XUse blue or black ink pen ONLY

OBSERVATION TYPE(Mark only one)

• •

A B C 1 2 3

0000001289208A OpScan iNSIGHT™ EM-289208-1:654321

© SCANTRON CORPORATION 2011 ALL RIGHTS RESERVED.

Basic Safety Form, Single-Sided

Behavior-Based Safety Obervation Card Front

Behavior-Based Safety Observation Card Back

Safety Observation Card Front

0000001290398A

Safety Observation CardPrint clearly inUPPERCASE letters.

Correct Mark: XA No red ink pen

OBSERVERID Number

Last Name

SITE / LOCATION (Mark only one)

DATE

__

Month Day Year

Ft. LauderdaleFt. WorthDenverMinneapolisAtlantaPhoenixSacramentoNew York

(Mark only one)1.0 Personal Protective Equipment

Eye / Face ProtectionHands ProtectionHead Protection

SAFE At-Risk1.11.21.3

2.0 Body Use and PositionWalkingClimbingLifting

2.12.22.3

Food ServiceVisitorSubcontractorOther

OBSERVER’S DEPARTMENT

(Mark only one)

Staff

B C 1 2 3

Safety Observation Card Back

290398B 0000001 SafetyCapture® EM-290398-1:654321 SF01

Category ID Comment (clip)

Comment (KFI)

SAFETY DIRECTOR SIGNATURE

(Mark only one)3.0 Workplace Conditions

LightingSurfaceHot Surface

SAFE At-Risk3.13.23.3

4.0 Transportation Cell Phone UseLightsBackup Alarm

4.14.24.3

Category ID

.

.

Section 2:SafetyCapture Desktop Sample Forms

Site Observation Card Front

LEARNINGOPPORTUNITY?

SITE OBSERVATION CARD

MO. DAY YEARDATE

••

• Use a No. 2 pencil or blue or black ink pen only.• Do not use pens with ink that soaks through the paper.• Make solid marks that fill the oval completely.

CORRECT

INCORRECT

Marking Instructions

OpScan iNSIGHTTM EM-290408-1:654321

EmployeeContractor

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PREPARED BY(EMPLOYEE

ID #)CONTRACTORS

Administration Contractor Maint/I&C Management Operations Corporate Professional Tech/Eng

Vikings Bears Lions Packers Pistons Wolves Twins Lynx Gophers Wild

RESPONSIBLE WORK GROUP

FOLD

TIME24-HOURCLOCK

Big Lake New York Cohasset Monticello Anoka Rush City Glenwood Marathon Milaca

Manalapan Beaumont Hardin Woodstock Flower Mound Minnetonka Canyon Lake Erie

Napa Hoover Plymouth Irvine Reed Springs Lutz Eagan Other

AT-RISKBEHAVIORS

NEARMISS

GOODCATCH

SITE

S E R I A L #COACHINGPROVIDED?

Battery Room Boiler Area Control Room Maint Shop/Tool Room Office Area/Admin Bldg Parking Lot Switchyard Turbine/Generator Area Warehouse/Storeroom Other

AREA

Yes No

OUTAGE

OBSERVER

SafetyCapture®

COMMENTS - COACHING

COMMENTS - LEARNING OPPORTUNITY

Yes No

Yes No

Yes No

Yes No

Yes No

Serial numbering to uniquely identify the form and related data

for reporting purposes

Site Observation Card Back

FOLD

If a positive observation(s) is selected, no mitigation should berequired. If a negative observation(s) is selected, a mitigationactivity is required. If a negative observation is selected and apositive observation is selected on the same card, a mitigationactivity is required.

Area Roped OffBarrier Installed Cleaned Area Coached Worker Corrected Housekeeping Created Work RequestDiscarded Trash Flagged Area

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

Electrical Safety Fall Protection Fire Protection Flammable Storage Hazard Communication Hot Work Job Hazard Analysis Ladder/Scaffold Use Lock Out/Tag Out Material Storage Motor Vehicle Safety Potential Hazard Rigging/Lifting Thermal Stress Tool Use

Asbestos Areas Chemical/Oil Leak Chemical Storage Construction Debris Drum storage Oil Waste Bins Pollution Control/

Storm Drains Scrap Bins Spill Equipment/

Containment

All PPE Being Worn Eye Protection Fall Protection Foot Protection Hand Protection/Gloves Hard Hat Protection Hearing/Ear Protection Respiratory Protection Other PPE

SAFETY

ENVIRONMENTAL

PPE

HUMAN PERFORMANCE

SECURITY

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

PLEASE CONTINUE ON THE OTHER SIDE

OBSERVATION

OBSERVATION/MITIGATION COMMENTS:

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

Accountability Attention to Detail Briefings Communication Foreign Material Exclusion Fork Truck Use Housekeeping Procedure Adherence Questioning Attitude Recordkeeping Verification Techniques

Badge Emergency Preparedness Property Breach Sabotage Suspicious Person/Package Tampering/Theft/Vandalism

+ –

+ –

MITIGATION (Select all that apply)

Installed Danger Tape Properly Labeled Properly Stored Material Removed Hazard Replaced Bulbs Reported to Management Stopped Job

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

Observation Card Front

? ? ?

Marking Instructions• Use a No. 2 pencil or blue or black ink pen only.• Do not use pens with ink that soaks through the

paper.• Make solid marks that fill the oval completely. • Only need to fill out sections that are applicable;

blank items will be assumed N/A.• Items marked “at risk” should have further details

in back comments section.

12

34

56

0123

0123456789

JANFEBMARAPRMAYJUNEJULYAUGSEPTOCTNOVDEC

DAY

20192020202120222023202420252026 2027 2028

YEAR

Date

At RiskYesNo

DaysAB

CDEmployeeContractorW

ork Area

APTTSOBoth

Warehouse

AssemblyFood ServiceRA / OdinRB / ThorRC / HeraRD / Loki

FacilitiesQCPackaging / ShippingW

arehouseAssemblyDocumentationLegalFood ServiceHSEEngineeringTrainingAdministration

YesNoYesNo

1.0 Personal Protective Equipment

Accident Prevention Technique/Task Safety Observation5.0 Jobsite Condition

2.0 Body Use & Movement

3.0 Vehicle Use

4.0 Job Planning/Permits

1.01 Hard Hat

1.02 Safety Glasses

1.03 Gloves (chemical, leather A/N)

1.04 Hearing Protection

1.05 Faceshields

1.06 Fall Protection

1.07 Respiratory Protection

1.08 Job Specific PPE

1.09 Safety Shoes

5.01 Barricade

5.02 Lighting

5.03 Container Labels

5.04 Cut/Puncture Hazard

5.05 Sparks/Slag Containment

5.06 Scaffolding

5.07 Struck By/Fall to Below Hazard

5.08 Slip/Trip Hazards

5.09 Area Congestion

2.01 Body Position

2.02 Line of Fire

2.03 Eyes on Task

2.04 Proper Lifting Technique

2.05 Ascending/Descending Stairs

2.06 Pinch Point

3.01 Speed

3.02 Seat Belt

3.03 Stop Sign

3.04 Cell Phone Use

3.05 Vehicle Operation

3.06 Vehicle in Authorized Area / Roadway

Safe

Safe

Safe

Safe

Safe

Safe

At Risk

At Risk

At Risk

At Risk

At Risk

At Risk

7.0 Use of Tools, Equip, Safety Devices

6.0 General Housekeeping

Continue on back

7.01 Gas Cylinder Secured

7.02 Tools/Equip. Condition

7.03 Correct Tool for Job

7.04 Electrical Ground/GFCI

7.05 Fire Extinguisher

7.06 Rigging

7.07 W

heel Chocks 7.08

Glad Hand Locks 7.09

Dock Locks 7.10

Jack Stand 7.11

Toe Boards 7.12

Handrail / Midrail 7.13

Machine Guarding 7.14

Fall Protection 7.15

Proper Supports / Bracing 7.16

Overhead Lift / Crane

6.01 Trash Bins

6.02 W

ater and Algae 6.03

Leaks and Spills 6.04

Misc. Trash/Clutter 6.05

Airborne Debris 6.06

Tools/Equip. Storage

Scantron SafetyCapture®

M-293208-2:654321 SF01

Packaging / ShippingGeneral GroundsAdministrationDevelopment LabMaintenance ShopsTraining Lab

Departments Audited

Observer Department

ShiftObserved

Outage

CI Generated

Type

4.01 Pre-Job W

alkdown 4.02

Safe Work Permit

4.03 Hot W

ork Permit 4.04

Confined Space Permit 4.05

Line Break Permit 4.06

Job Safety Analysis 4.07

Excavation Checklist 4.08

Critical Lift Plan 4.09

Lockout/Tagout 4.10

Scaffold Tags 4.11

Communication/Radios/etc. 4.12

Fire Watch/Hole W

atch 4.13

Process Equipment Cleared/Cleaned 4.14

Safety Equipment/Devices Available 4.15

Escape Routes Available

AFI LOS ANGELESSafety Observation Card

SafeAt Risk

CO

RR

ECT

INC

OR

REC

T

SafeAt Risk

8.0 Human Performance 8.01

Procedure Does Not Exist 8.02

Procedure Inadequate 8.03

Training Inadequate 8.04

Failure to Follow Plant Signage /Policy

?

Observation Card Back

Safe

At R

isk

9.0

Offi

ce E

rgon

omic

s 9

.01

Trip

ping

Haz

ard

9.0

2 M

onito

r - a

ngle

/dis

tanc

e/

gl

are/

brig

htne

ss 9

.03

Keyb

oard

/Mou

se h

eigh

t, di

stan

ce 9

.04

Cha

ir H

eigh

t/Lum

bar S

uppo

rt 9

.05

Post

ure/

Body

Pos

ition

9.0

6 W

orks

pace

Hou

seke

epin

g

Acci

dent

Pre

vent

ion/

Task

Saf

ety

Obs

erva

tion

(con

t.)

Com

men

tsAddi

tiona

l Con

cern

s

Categ

ory I

D

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Categ

ory I

D

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men

ts

Categ

ory I

D

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Categ

ory I

D

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Follo

w-u

p/Ac

tion

Item

Tak

en:

Follo

w-u

p/Ac

tion

Item

Tak

en:

Follo

w-u

p/Ac

tion

Item

Tak

en:

Not

ifica

tion

Not

ifica

tion

Not

ifica

tion

Con

vers

atio

n

Con

vers

atio

n

Con

vers

atio

n

Coac

hing

Opp

ortu

nity

Coac

hing

Opp

ortu

nity

Coac

hing

Opp

ortu

nity

ACC

IDEN

TPR

EVEN

TIO

N

And

TASK

SAF

ETY

OBS

ERVA

TIO

NC

ARD

Los

Ange

les

Plan

t

WOR

KING

TOG

ETHE

R TO

BUI

LD

A CU

LTUR

E OF

SAF

ETY

Whil

e? (d

oing t

ask):

NOTO

#

Wha

t? (w

as th

e risk

):

Why

? (be

caus

e):

Solut

ion D

iscus

sed:

Whil

e? (d

oing t

ask):

NOTO

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Wha

t? (w

as th

e risk

):

Why

? (be

caus

e):

Solut

ion D

iscus

sed:

Whil

e? (d

oing t

ask):

NOTO

#

Wha

t? (w

as th

e risk

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Why

? (be

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Solut

ion D

iscus

sed:

Customizable Form Front

MONTH DAY YEAR

0123

0123456789

0123456789

0123456789

0123456789

0123456789

0123456789

0123456789

Observer ID

Date

JanFebMarAprMayJunJulyAugSepOctNovDec

201620172018201920202021202220232024202520262027

Scantron SafetyCapture® W-297819-1:654321 SF01

Customizable Form Back

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30Item No:Comments

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30Item No:Comments

Customizable Form Front—General Safety Overprint

MONTH DAY YEAR

0123

0123456789

0123456789

0123456789

0123456789

0123456789

0123456789

0123456789

Observer ID

Date

JanFebMarAprMayJunJulyAugSepOctNovDec

201620172018201920202021202220232024202520262027

Scantron SafetyCapture® W-297819-1:654321 SF01

All Facilities OverviewCompany Observed

Employee Status

Employee Class Incident Class Site Location

Acme Electric

Apex Food Svc

Crest Constr

Max Mfring

Peak Perf LLC

Vertex Inc

FT Salary

FT Hourly

PT Hourly

Contractor

Seasonal Hrly

Administrative

Engineer

Tech Support

Technician

Mfring Line

Shipper

DriverFacilities

All Safe

Near Miss

Sign Near Miss

Environmental

Medical

Office

Docks

Cafeteria

Facil’s Shop

Control Room

Electrical Shop

Fitness Center

Fuel Depot

Road

Laboratory

Mfring FloorMachine Shop

Warehouse

Mark Safe, At Risk or NA SAFE AT RISK

Body Use and Movement

1. Body Position

2. Line of FIre

3. Eyes on Task

4. Bending / Twisting / Lifting

5. Use of Ladder / Step Stool

NA

6. Ascending / Descending

7. Pinch Point

8. Pushing / Pulling /Overextending

9. Thermal Stress

10. Repetitive Motion

Customizable Form Back—General Safety Overprint

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30Item No:Comments

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30Item No:Comments

Mark Safe, At Risk or NA SAFE AT RISK NA

Job Planning

11. Stacked Jobs / Congestion

12. Safe Work Permit

13. Fire Watch

14. Communication

Use of Tools and Equipment

15. Safety Device

16. Gas Cylinder Security

17. Correct Tool Usage

18. Electrical Grounding

19. Tool in Good Condition

20. Chemical Containment

21. Guards in Place

Near Miss Medical Work Order

Near Miss Medical Work Order

Customizable Form Front—Perception Overprint

“No business objective is so important that it will be pursued at the sacrifice of safety.”

Craft:Company Name:

At Enercon, we believe our people are our greatest asset. What you think of Enercon and its management is extremely important to us. Please take a moment to complete the survey so that we can better identify and improve deficiencies in our health and safety management, processes, and procedures.

Admin.BoilermakerCarpenter

ElectricianIronworkerLaborer

Manager/SupervisorMasonryOperator

PainterPipe FitterTeamster

Upper management of this company…

My direct supervisor…

1. Reacts quickly to solve the problem when told about safety hazards. 2. Insists on thorough and regular safety audits and inspections. 3. Tries to continually improve safety levels in each department. 4. Provides all equipment needed to do the job safely. 5. Is strict about working safely when work falls behind schedule . 6. Quickly corrects any safety hazard (even if it’s costly) . 7. Provides detailed safety reports to workers (Top 3 Safety Concerns,

corrective actions from incidents). 8. Invests a lot of time and money in safety training for workers. 9. Uses any available information to improve Enercon’s safety culture. 10. Listens carefully to workers’ ideas about improving safety. 11. Considers safety when setting pr oduction speed and schedules. 12. Provides workers with information on safety issues. 13. Regularly holds safety-awareness events (e.g., presentations, ceremonies). 14. Gives safety personnel the power they need to do their job. 15. Believes that “No business objective is so important that it will be pursued

.”

1. Makes sure we receive all the tools/equipment needed to do the job safely. 2. Frequently checks to see if we are working safe. 3. Discusses how to impr ove safety with us. 4. Uses explanations (not just compliance) to get us to act safely . 5. Emphasizes safety procedures when we are working under pressure. 6. Frequently tells us about the hazards in our work. 7. Refuses to ignore safety rules when work falls behind schedule. 8. Is strict about working safely when we are tired or stressed. 9. Makes sure we follow all the safety rules (not just the most important ones). 10. 11. Says a “good wor d” to workers who pay special attention to safety. 12. Is strict about safety at the end of the shift, when we want to go home. 13. Spends time helping us learn to see problems before they arise. 14. Frequently talks about safety issues throughout the workweek. 15. Believes that “No business objective is so important that it will be pursued .”

Use No. 2 pencil orblack pen and

INCORRECT MARKS

CORRECT MARK

INSTRUCTIONS

COMMENTS:

STRONGLYDISAGREE

STRONGLYDISAGREE

DISAGREE

DISAGREE

NEUTRAL

NEUTRAL

AGREE

AGREE

STRONGLYAGREE

STRONGLYAGREE

JanFebMarAprMayJuneJulyAugSeptOctNovDec

2019

2020

2021

DATEYEARMONTH

Scantron OpScan iNSIGHT™ M-302665-1:654321 SF01

Safety Perception Survey

SERIAL NO.

CAMPAIGN NO.

Observation Form Front

Location

No. Observed

Observation FormMarking Instructions

CORRECT INCORRECT• Use a No. 2 pencil or blue or black ink pen only.• Do not use pens with ink that soaks through the paper.• Make solid marks that fill the oval completely.

S E R I A L #

Continue on backRev. 1216

FOLD

Print FloorShippingOfficeLoad BayStorageWarehouse Facilities Shop

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JANFEBMARAPRMAYJUNEJULYAUGSEPTOCTNOVDEC

DAY

20192020202120222023 2024 2025202620272028

YEAR

Date

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Observer ID

Normal Wet Operations/Products

Maintenance

ContractorSalary

Hot

Turnaround

Yes No

Ice/SnowCold

Work Mode

Follow Up Requested on this Observation

WeatherClassification

•While doing (describe task)

The employee was (describe behavior)

Because (Why was at-risk being done?)

Suggestions for improvement

Aware?

Commitment to try?

Agree?

Easy Difficult Impossible

Control?

0

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CBI#

Chemical StorageMail Sorting Cutting Room Recycling Area Motor PoolDigital Print FloorWaste Storage

Parking Lot PowerplantBackup Generation

0

Normal

0000

Observation Form Back

SafetyCapture® EM-299055-2:654321

FOLD

1.0 BODY USE

CBI CATEGORY

2.0 WORKING CONDITIONS

3.0 PPE

4.0 PROCEDURE

6.0 OTHER BEHAVIORS

5.0 TOOLS/EQUIPMENT/VEHICLES

1.1 Ascending/Descending1.2 Assistance1.3 Body Mechanics/Ergonomics1.4 Eyes on Path 1.5 Eyes on Task1.6 Line of Fire 1.7 Pinch Points

2.1 Housekeeping2.2 Lighting/Visibility2.3 Walking/Working Surfaces

3.1 Body Protection3.2 Eyes/Face Protection3.3 Fall Protection3.4 Hand Protection3.5 Foot Protection3.6 Hearing Protection3.7 Head Protection3.8 Respiratory Protection3.9 H2S Monitor

4.1 Communications4.2 Permits

5.1 Selection/Use5.2 Condition5.3 Barricades

6.1 Other

Observation

SAFE

SAFE

SAFE

SAFE

SAFE

SAFE

AT-RISK

AT-RISK

AT-RISK

AT-RISK

AT-RISK

AT-RISK

•While doing (describe task)

The employee was (describe behavior)

Because (Why was at-risk being done?)

Suggestions for improvement

Aware?

Commitment to try?

Agree?

Easy Difficult Impossible

Control?

0

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CBI#