HSE Behaviour Observation Report

• Customer Name

• Type of Work

• Date

  Date

• Conducted by

• Location
  Address

• Number of Persons Observed

• Instruction: any item identified as "no" or at risk requires a documented action. All Reports must be kept as evidence. Email to yourself or your administrator and save in local teamroom or designated folder. File naming convention: include type, month/yr and your name/initials.

Readiness of People

• Changing position

  Safe

  At Risk

  N/A

• Stopping work

  Safe

  At Risk

  N/A

• Rearranging task or job

  Safe

  At Risk

  N/A

• Hiding or dodging

  Safe

  At Risk

  N/A

• Changing tools

  Safe

  At Risk

  N/A

• Applying Lockout Tagout

  Safe

  At Risk

  N/A

• Adjusting PPE

  Safe

  At Risk

  N/A

Position of People

• Striking against

  Safe

  At Risk

  N/A

• Caught in-between

  Safe

  At Risk

  N/A

• Heat or Cold Stress

  Safe

  At Risk

  N/A

• Inhaling (chemical, dust, etc.)

  Safe

  At Risk

  N/A

• Absorbing (chemical)

  Safe

  At Risk

  N/A

• Electrical

  Safe

  At Risk

  N/A

• Hazardous energy

  Safe

  At Risk

  N/A

• Falling different level

  Safe

  At Risk

  N/A

• Slip, trip, fall same level

  Safe

  At Risk

  N/A

• Struck by

  Safe

  At Risk

  N/A

• Vehicle or moving equipment

  Safe

  At Risk

  N/A

• Other:

PPE personal protective equipment right for task and properly fitted, inspected and used

• Head

  Safe

  At Risk

  N/A

• Eyes

  Safe

  At Risk

  N/A

• Face (face-shield used with safety glasses)

  Safe

  At Risk

  N/A

• Ears (muffs, foam or custom ear plugs)

  Safe

  At Risk

  N/A

• Respiratory system (seal, dust mask, half- or full face respirator, cartridge type -duration of use, all bands in place, clean shaven)

  Safe

  At Risk

  N/A

• Hands and arms (glove type, size, cut-proof sleeves, no jewelry, sleeves)

  Safe

  At Risk

  N/A

• Feet and legs (boot or shoe type, pants)

  Safe

  At Risk

  N/A

• Other PPE:

Tools and/or Equipment

• Right for the task or job

  Yes

  No

  N/A

• Used correctly

  Yes

  No

  N/A

• In safe good condition

  Yes

  No

  N/A

• Harness, SRL etc. Inspected & in good condition

  Yes

  No

  N/A

• Gloves right for task

  Yes

  No

  N/A

• Ladders, platforms, Barricades, railings in good condition & right for task

  Yes

  No

  N/A

• Warning (signs, alarms, etc.) in place & functional

  Yes

  No

  N/A

• Pre-job inspections completed & deviations corrected

  Yes

  No

  N/A

• Monitoring and/or measuring equipment in good condition & calibrated

  Yes

  No

  N/A

• Other:

Procedures

• Standard right for task or job

  Yes

  No

  N/A

• Standard readily available

  Yes

  No

  N/A

• Standard up-to-date

  Yes

  No

  N/A

• Permit to work in place, current, and complete

  Yes

  No

  N/A

• Fire watch in place

  Yes

  No

  N/A

• Gas testing completed documnted

  Yes

  No

  N/A

• Zero energy state verified

  Yes

  No

  N/A

• Emergency rescue in place

  Yes

  No

  N/A

• Other:

5S Orderliness & Tidyness

• Standard in place & understood

  Yes

  No

  N/A

• Work area organized

  Yes

  No

  N/A

• Well-organized tools

  Yes

  No

  N/A

• Material storage right (hazmat 2-dary containment, shelving, etc.)

  Yes

  No

  N/A

• Stairs/platforms location (controlled access if in pathway)

  Yes

  No

  N/A

• Obstructions (adequate egress/ entrance)

  Yes

  No

  N/A

Behaviour Observation Team Member(s)

• Name and signature

  Sign

• Name and signature

  Sign

• Name and signature

  Sign

• Name and signature

  Sign