Back
General • Inspections

(FORM) OSM 1.26 Exhibit 2 High Hazard Safety Observation

This form is used to document observations related to high hazard activities or conditions in the workplace. It supports proactive hazard identification and risk mitigation by capturing details such as the location, nature of the hazard, personnel involved, control measures in place, and any corrective actions required. Observations may include activities involving working at heights, confined spaces, energized equipment, heavy machinery, or chemical exposure. The goal of this form is to promote a strong safety culture by ensuring timely reporting, assessment, and resolution of high-risk scenarios in compliance with operational safety standards.
UNVR - 0917 - Rowell
07/17/2025

(FORM) OSM 1.26 Exhibit 2 High Hazard Safety Observation

This form is used to document observations related to high hazard activities or conditions in the workplace. It supports proactive hazard identification and risk mitigation by capturing details such as the location, nature of the hazard, personnel involved, control measures in place, and any corrective actions required. Observations may include activities involving working at heights, confined spaces, energized equipment, heavy machinery, or chemical exposure. The goal of this form is to promote a strong safety culture by ensuring timely reporting, assessment, and resolution of high-risk scenarios in compliance with operational safety standards.

    High Hazard Safety Observation

    Section #1

    Who's Being Observed?

    if the answer is "oneOf [Contractor]"

    Name of Contractor

    if the answer is "oneOf [Employee(s)]"

    Name(s) of Employee(s)

    Section #2

    Date of Observation:

    Observations

    Section #3

    What Type(s) of Observation is Being Conducted?

    if the answer is "oneOf [Working at Heights]"

    Are proper PPE and fall protection/prevention devices available and being used correctly? (e.g. lanyard, harness, etc.)

    • Yes
    • No
    • N / A

    Are portable, fixed, and rolling ladders free from defects?

    • Yes
    • No
    • N / A

    Are portable ladders that are not being used stored and secured?

    • Yes
    • No
    • N / A

    Are employees/contractors using fall protection correctly while performing work ≥ 4 feet?

    • Yes
    • No
    • N / A

    Are warning signs clearly visible next to storage tanks indicating “Authorized employees only-JSA must be performed-Employees must use fall protection device”?

    • Yes
    • No
    • N / A

    Are portable, fixed, and rolling ladders being used correctly and only for intended purpose?

    • Yes
    • No
    • N / A

    Are all straight, extension, and A-frame ladders <12’ in height?

    • Yes
    • No
    • N / A

    Is the work area organized and free from any recognized hazards?

    • Yes
    • No
    • N / A
    if the answer is "oneOf [Confined Space]"

    Is proper PPE available and being used correctly?

    • Yes
    • No
    • N / A

    Is the work area organized and free from any recognized hazards?

    • Yes
    • No
    • N / A

    Entry-specific SOP available for work being performed?

    • Yes
    • No
    • N / A

    Has the atmosphere in the confined space been checked and monitored for oxygen, LEL, CO, H2S, and any other toxic gasses?

    • Yes
    • No
    • N / A

    Are all permit-required confined spaces clearly identified by warning signs? (Warning signs must be easy to read and free from defects)

    • Yes
    • No
    • N / A

    Has all LOTO been performed, documented, and reviewed by the employee/contractor performing the work?

    • Yes
    • No
    • N / A

    Are all retrieval devices (winch, tripod, etc.) being used

    • Yes
    • No
    • N / A

    Is a qualified rescue team present?

    • Yes
    • No
    • N / A

    Is a qualified rescue team present?

    • Yes
    • No
    • N / A

    Are all permits filled out completely and posted in areas where work is being performed?

    • Yes
    • No
    • N / A

    Was a confined space pre-entry meeting performed using OSM 1.26 Exhibit 5?

    • Yes
    • No
    • N / A

    Was an initial inventory of all confined spaces performed using OSM 1.26 Exhibit 4: Confined Space Inventory?

    • Yes
    • No
    • N / A
    if the answer is "oneOf [Lockout/Tagout (LOTO)]"

    Is proper PPE available and being used correctly?

    • Yes
    • No
    • N / A

    Is the work area organized and free from any recognized hazards?

    • Yes
    • No
    • N / A

    Are all LOTO devices (hasps, clasps, locks, and tags) free from defects and used properly?

    • Yes
    • No
    • N / A

    Have all forms been completed and posted in areas where work is being performed?

    • Yes
    • No
    • N / A

    Have all affected employees been informed that LOTO work is being performed?

    • Yes
    • No
    • N / A

    Are all steps in the energy control procedure being followed?

    • Yes
    • No
    • N / A

    Do authorized employees understand their responsibilities under the LOTO procedure?

    • Yes
    • No
    • N / A

    Is the current procedure adequate to provide the necessary protections?

    • Yes
    • No
    • N / A

    Have all equipment-specific procedures (OSM 1.22 Exhibit 1) been observed and certified annually?

    • Yes
    • No
    • N / A
    if the answer is "oneOf [Hot Work]"

    Is proper PPE available and being used correctly?

    • Yes
    • No
    • N / A

    Is the work area organized and free from any recognized hazards?

    • Yes
    • No
    • N / A

    Is the designated working area ≥50 feet from any process pipes or storage of flammable or combustible materials?

    • Yes
    • No
    • N / A

    Is designated hot work area map posted?

    • Yes
    • No
    • N / A

    Are combustible materials removed from Hot Work area or properly shielded

    • Yes
    • No
    • N / A

    Is there a fully-charged fire extinguisher readily available?

    • Yes
    • No
    • N / A

    Is hot work equipment being used in good condition?

    • Yes
    • No
    • N / A

    Was there an authorized fire watch present who remained in area for 30 minutes after work was completed?

    • Yes
    • No
    • N / A

    Are protective screens free from defects being used?

    • Yes
    • No
    • N / A

    Is work on PSM-covered processes completed in compliance with Univar Solutions updated PSM plan?

    • Yes
    • No
    • N / A

    Was the hot work permit completely filled out and posted in the area where work is being performed?

    • Yes
    • No
    • N / A

    Are employees performing Hot Work listed on the Branch Authorized Employee list?

    • Yes
    • No
    • N / A

    Are employee/contractor training files complete including welder certifications?

    • Yes
    • No
    • N / A

    If you observe any unsafe conditions, exercise stop work authority immediately

    Section #4

    Comments or Corrective Actions

    if the answer is "oneOf [Working at Heights]"

    Comments or Corrective Actions

    if the answer is "oneOf [Confined Space]"

    Comments or Corrective Actions

    if the answer is "oneOf [Lockout/Tagout (LOTO)]"

    Comments or Corrective Actions

    if the answer is "oneOf [Hot Work]"

    Comments or Corrective Actions

    Section #5

    Completed by:

    Section #6

    Signature:

    Click here to sign
Source: UNVR - 0917 - Rowell (Community Member)

Please note that any procedure, checklist, or other document available in the MaintainX Procedure Hub is provided for general education and information only and does not constitute legal, medical, or financial advice. MaintainX makes the materials available AS IS and AS PROVIDED, without warranties of any kind. By downloading or using any such materials, you assume the risk that they may not be appropriate for your specific situation and agree that you are solely responsible for any such use, including compliance with applicable law and with meeting any conditions of product warranties.