Compass Observation Card

1

Division* This field is required

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2

Job Name or Location* This field is required

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3

Date of Observation* This field is required

Date

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4

Do you wish to submit this anonymously?* This field is required

Yes

No

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5

Supervisor's Name* This field is required

First Name

Last Name

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6

Type of Observation* This field is required

Safety Excellence

Unsafe Condition

Unsafe Behavior

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8

Unsafe Behavior* This field is requiredCheck all that apply.

Improper or no PPE

Improper tool or equipment use

Complacent or poor safety attitude

Not following safety policy

Not following safe work practices

Willfull unsafe behavior

Unwilling to heed correction

Put self or others in danger

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9

What did you observe?* This field is requiredExplain what you saw in your own words.

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10

What did you do about it?* This field is requiredHow was it addressed or corrected? What can we do to help?

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11

Who else was involved?Let us know who our safety champions are!

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12

IMAGES LARGER THAN 8MB MAY PREVENT YOUR SUBMISSION FROM REACHING US!

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13

Your Name* This field is requiredTell us who is submitting this observation.

First Name

Last Name

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14

Your Signature* This field is required

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15

Date and Time of Submission

Date

Hour

Minutes

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