Behavior Based Safety Observations

• Conducted on

  Date

• Prepared by

• Location
  Address

General Work Area

• Select date

  Date

• Evacuation routes are posted and known

  Safe

  At Risk

  N/A

• Safety equipment (eye washes, AED, First Aid, etc.)

  Safe

  At Risk

  N/A

• Racking systems

  Safe

  At Risk

  N/A

• Knife Use/Cut Exposure

  Safe

  At Risk

  N/A

• Fall protection use (includes ladder, harnesses, etc.)

  Safe

  At Risk

  N/A

• Works at safe pace, not rushed

  Safe

  At Risk

  N/A

• Chemicals stored in designated area and labels visible and clear (includes flammables)

  Safe

  At Risk

  N/A

• Aisles/clearances maintained

  Safe

  At Risk

  N/A

• Equipment and other furnishings appropriate and maintained

  Safe

  At Risk

  N/A

• General housekeeping

  Safe

  At Risk

  N/A

• Hazards - Slip/trip/falls

  Safe

  At Risk

  N/A

• Fire Protection

  Safe

  At Risk

  N/A

• Electrical equipment condition (rust, panels closed, labels, no frayed wires, etc.)

  Safe

  At Risk

  N/A

• Workers aware of how to obtain Safety Data Sheets (SDSs) as applicable

  Safe

  At Risk

  N/A

• Workers aware of how to report a near miss or other incident

  Safe

  At Risk

  N/A

• General Safety (signage, procedures, etc.)

  Safe

  At Risk

  N/A

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  Sign

Personal Protective Equipment (PPE)

• Please enter date of this inspection

  Date

• Arm Protection

  Safe

  At Risk

  N/A

• Face/Respirator Protection (Dust masks, respirator (half or full face), face shield, etc.)

  Safe

  At Risk

  N/A

• Hand Protection

  Safe

  At Risk

  N/A

• Hearing Protection

  Safe

  At Risk

  N/A

• Eye Protection

  Safe

  At Risk

  N/A

• Foot Protection

  Safe

  At Risk

  N/A

• Head Protection

  Safe

  At Risk

  N/A

• High Visibility Vest (Warehouse/Visitors)

  Safe

  At Risk

  N/A

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  Sign

Powered Industrial Trucks (Forklifts, Golf Carts, etc.O

• Please enter date of this inspection

  Date

• 3 point mount/dismount

  Safe

  At Risk

  N/A

• Attachment conditions

  Safe

  At Risk

  N/A

• Horn in use as needed

  Safe

  At Risk

  N/A

• Load deploy/Load engage

  Safe

  At Risk

  N/A

• Load within rated capacity

  Safe

  At Risk

  N/A

• Parking as appropriate

  Safe

  At Risk

  N/A

• Traveling - Fork height appropriate

  Safe

  At Risk

  N/A

• Traveling - Load secured

  Safe

  At Risk

  N/A

• Appropriate speed

  Safe

  At Risk

  N/A

• Awareness and driver free of distractions

  Safe

  At Risk

  N/A

• Driver looks before moving

  Safe

  At Risk

  N/A

• Driver using seat belt

  Safe

  At Risk

  N/A

• Limbs kept inside of vehicle

  Safe

  At Risk

  N/A

• Pre-flight inspections completed

  Safe

  At Risk

  N/A

• Following distance appropriate

  Safe

  At Risk

  N/A

• TAKE 5 conducted

  Safe

  At Risk

  N/A

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  Sign

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  Date

• Movement - Lifting

  Safe

  At Risk

  N/A

• Movement - Pushing/Pulling

  Safe

  At Risk

  N/A

• Movement - Repetitive Motion

  Safe

  At Risk

  N/A

• Movement - Bending

  Safe

  At Risk

  N/A

• Movement - Posture

  Safe

  At Risk

  N/A

• Movement - Reaching

  Safe

  At Risk

  N/A

• Movement - Twisting

  Safe

  At Risk

  N/A

• Lifts with Legs and not Back

  Safe

  At Risk

  N/A

• List Assist for Heavy Loads (i.e. hoists, helper, etc.)

  Safe

  At Risk

  N/A

• Throwing

  Safe

  At Risk

  N/A

• Job/Task Rotation

  Safe

  At Risk

  N/A

• Travel Distance

  Safe

  At Risk

  N/A

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  Sign

• Please enter date of inspection

  Date

• Dock Lights Operating Properly

  Safe

  At Risk

  N/A

• Dock Leveler Operating Properly

  Safe

  At Risk

  N/A

• Trailer Wheels Chocked/Hook Attached to Trailer

  Safe

  At Risk

  N/A

• Trailer Aligned to Dock Door as appropriate

  Safe

  At Risk

  N/A

• Dock Doors Opening Properly

  Safe

  At Risk

  N/A

• Trailer Jack Stands in Place

  Safe

  At Risk

  N/A

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  Sign

• Please enter date of this inspection

  Date

• Debris/housekeeping outside buildings

  Safe

  At Risk

  N/A

• Recycling use and/or waste generation

  Safe

  At Risk

  N/A

• Spills/Leaks

  Safe

  At Risk

  N/A

• Container Condition

  Safe

  At Risk

  N/A

• Container Labeling

  Safe

  At Risk

  N/A

• Outside Air Quality

  Safe

  At Risk

  N/A

• Containers Compatible with Contents

  Safe

  At Risk

  N/A

• Water Conservation in Use

  Safe

  At Risk

  N/A

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  Sign

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  Date

• Barriers/Guards/Light Curtains

  Safe

  At Risk

  N/A

• E-stops/Interlocks

  Safe

  At Risk

  N/A

• Pinch Points

  Safe

  At Risk

  N/A

• Belts/Chains/Pulleys/Rollers

  Safe

  At Risk

  N/A

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  Sign

Lockout/Tagout (LOTO)

• Please enter date of this inspection

  Date

• LOTO Procedures Posted or available near work station

  Safe

  At Risk

  N/A

• LOTO Points Labeled

  Safe

  At Risk

  N/A

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  Sign

• Please enter date of this inpsection

  Date

• Aware and free of distractions

  Safe

  At Risk

  N/A

• Pedestrian/Lift Truck Interface

  Safe

  At Risk

  N/A

• Stopping at Stop Signs

  Safe

  At Risk

  N/A

• Looks before Entering Aisles & Check blind spots

  Safe

  At Risk

  N/A

• Holds handrails when ascending or descending stairs

  Safe

  At Risk

  N/A

• Walking in designated pedestrian pathways

  Safe

  At Risk

  N/A

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