Behavior Based Safety Observation Form

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

1.0 PPE

• Eyes: protected from flying debris, chemicals and radiant light. Safety glasses worn in mandatory areas?

  Safe

  At Risk

  N/A

• Hearing: protection used in mandatory areas and during short exposures to high decibel noise?

  Safe

  At Risk

  N/A

• Body, Arms, and Hands: protected from resins, adhesives, sealants, chemicals and composite dust

  Safe

  At Risk

  N/A

• Hands: protected when handling sharp objects/tools, severely hot or cold items

  Safe

  At Risk

  N/A

• Head: protected from impact from above and at same height objects?

  Safe

  At Risk

  N/A

• Respiratory: protected for vapors, dust, misc. debris. Clean shaven, mask stored in sealed container

  Safe

  At Risk

  N/A

2.0 Ergonomics

• Lifting/Lowering: weights not above 50# at/above shoulder height. Lift is not awkward or repetitive?

  Safe

  At Risk

  N/A

• Pushing: versus pulling?

  Safe

  At Risk

  N/A

• Reach: not overextended for long periods of time or during lifting?

  Safe

  At Risk

  N/A

• Grip/force: not excessive when combined with high frequency?

  Safe

  At Risk

  N/A

• Repetition: is not excessive not excessive when combined with high force and frequency?

  Safe

  At Risk

  N/A

• Vibration: long exposures reduced by PPE, tape or tool design?

  Safe

  At Risk

  N/A

• Body Posture: wrist, neck back in neutral position, elbows 90, close to body?

  Safe

  At Risk

  N/A

3.0 Tools and Equipment

• Razor Blades: stored when not used, cut resistant gloves worn

  Safe

  At Risk

  N/A

• Fixtures/Carts/Racks: breaks, wheels and gen. frame operational. Pinch point iD'd

  Safe

  At Risk

  N/A

• Tools/hoist: safety triggers operational, periodic checks done, no signs or wear or failure

  Safe

  At Risk

  N/A

• 6S: clean as you go is evident<br>

  Safe

  At Risk

  N/A

4.0 Employee Suggestions and Comments

• Yes

  No

  N/A