Behavior Based Safety Observation

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

GENERAL INFORMATION

• Observers name

• Employee observed

• Date and time of observation

  Date

• Select Department where observation occurred

  Select Press Jogging Cutter PMC HandHelp palletizing warehouse Sheeter forklift use Plateroom raw material press room

  • Press
  • Jogging
  • Cutter
  • PMC
  • HandHelp
  • palletizing
  • warehouse
  • Sheeter
  • forklift use
  • Plateroom
  • raw material press room

OBSERVATIONS

• Describe positive behaviors observed

• Photos if helpful

  Media

• Describe conversation with associate about positive behaviors

• Describe each at risk behavior

At Risk Behavior

• Describe behavior observed

• Photos showing risks

  Media

• Describe preventative action discussed with employee

• Photo showing preventative actions/behaviors

  Media

REVIEW

• Observer name and signature

  Sign

• Observer 2 name and signature

  Sign

• Employee name and signature

  Sign

Safety Committee Review

• Comments - Recommendations

• Photos

  Media

• Drawings

  Drawing

• Review Date

• General Manager signature

  Sign