Behavior Based Safety Observation

Document Number *

Date *

Project *

Street Address

City *

State/Province *

ZIP / Postal Code

Prepared by *

Personnel *

Housekeeping

Aisles/Walkways kept clear? *SafeAt RiskN/A

Work area kept organized? *SafeAt RiskN/A

Housekeeping: spills, cords, or other trips, trash/clutter, lighting, or flammables *

Personal Protective Equipment

All appropriate equipment or gear worn correctly? *SafeAt RiskN/A

PPE kept in good condition *SafeAt RiskN/A

Personal protective equipment: hand, body, eyes/face, head, foot, respiratory, fall protection, hearing protection, or FR clothing/gear *

Working Position

Body position *SafeAt RiskN/A

Location in working environment *SafeAt RiskN/A

Working position: poor posture, over stretched, above shoulder, below knees, twisting, caught in between, struck by, working at heights greater than 4', floor or wall opening, unprotected work edge, or false ceiling or floor *

Tools & Equipment

Appropriate tools or equipment being used *SafeAt RiskN/A

Tools or equipment being used correctly *SafeAt RiskN/A

Tools or equipment in good condition *SafeAt RiskN/A

Tools & equipment: ladders, power or hand tools *

Safety Procedures

Lock-out/Tag-out, Arc Flash, Hot Work Permit, Confined Space *SafeAt RiskN/A

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Analysis

Safe behaviors observed/actions taken to encourage safe behavior *

Unsafe behaviors observed/action taken to correct and prevent recurrence *

Line of fire *

Signature *

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