Leavitt Group 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

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

  Safe

  At Risk

  N/A

• Body, Face, Arms, and Hands protected from chemicals?

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

• Hearing protection used in mandatory areas?

  Safe

  At Risk

  N/A

• Fall protection offered and used properly?

  Safe

  At Risk

  N/A

2.0 Ergonomics

• Lifting/Lowering: weights not above 50#?

  Safe

  At Risk

  N/A

• Lifting above shoulder height?

  Safe

  At Risk

  N/A

• Lift is not awkward or repetitive?

  Safe

  At Risk

  N/A

• Are back supports offered? If so, are they worn properly?

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

• Pushing versus pulling?

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

3.0 Tools and Equipment

• Razor Blades stored when not used? Cut resistant gloves/sleeves required and used?

  Safe

  At Risk

  N/A

• Fixtures/Carts/Racks: breaks, wheels and general frame operational? Pinch point Identified?

  Safe

  At Risk

  N/A

• Housekeeping good?<br>

  Safe

  At Risk

  N/A

• Tools/ladders/hoists in good repair? Inspected? Right for the job? Used properly?

  Safe

  At Risk

  N/A

• Forklifts inspected, operated safely and at walking pace?

  Safe

  At Risk

  N/A

• Is equipment being operated with all guards in place?

  Safe

  At Risk

  N/A

• Barricading adequately used if required?

  Yes

  No

  N/A

General

• Employees working at safe speed?

  Safe

  At Risk

  N/A

• Manager visible?

  Yes

  No

  N/A

4.0 Employee Suggestions and Comments

• Yes

  No

  N/A

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