Daily Safety Report
A DSR is the daily observation for for Regional Safety Managers. This is a report of the observations made while Regional Safety Managers are onsite. This is required for all visits to field employees.
Date Safety Observation Performed
*
/
Month
/
Day
Year
Date
List the Employees
*
Directors Name
*
Director, Senior Director or VP
Regional Safety Manager (RSM) Name
*
Regional Safety Manager (RSM) Email
*
An email is required to receive a copy of the report.
Project Name or Office Location
*
client name is also acceptable
Client Name
*
client name is also acceptable
Region
*
Please Select
LD East
LD West
LD Southeast
LD Central
Hydrocarbon
Power
Natural Resources
Corporate services
Specialty Services
RVi
SCS
Centurion
State
*
State
Type of Contact/ Interaction
*
Field
Office
Phone
Team/Email
Other
Describe the Safety interaction and observation
*
Safety Assessment
*
Report Only
Unsafe Behavior
Unsafe Conditions
JHA Completed
*
Yes
No
N/A
If No why?
Potential Hazards Onsite
Lack of PPE
Severe Weather/Unsafe Driving Condition
Exposure to Extreme Temps (cold/hot)
Exposure to Construction Traffic
Engulfment (Excavation)
Lack of Warning Signage
Exposure to Vehicle Traffic
Contact with Insect/Animal Bite
Fatigue - Exhaustion
Fall (From Elevation)
Fall (Same Level)
Transportation
Lifting - Repetitive Motion
Struck-By
Caught In/Between
Electrocution
Contact with Sharp Object
Exposure to Chemical
Oxygen Deficiency
Fire Hazard
Improper Storage or Use of Equipment
Lack of Guarding /Shielding
Lack of Housekeeping - Sanitation
Lack of Light - Illumination
Other (Use "Additional Info" Section)
Other
Take Photo
Take Photo
Is there any Corrective Actions for this report
*
Yes
No
Describe any Corrective Action that need to be assigned: (How can we improve the observed condition or behavior?) (Be Specific)
Date Corrective Actions to be completed
/
Month
/
Day
Year
Date
Additional Follow-up Information
Use for follow up information gathered as the issue is closed out
Person Responsible for Completing Corrective Actions
Email of the Person Responsible for Completing Corrective Actions
example@example.com
Daily Safety Report status
*
Open
Closed
Daily Safety Report Closure Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: