PVNA Behavioral Observation Card

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• Department

  Select

Initial Actions

• Mind/Eyes on Task

  Safe

  At Risk

  N/A

• Not Rushing

  Safe

  At Risk

  N/A

• Slip Trips and Falls

  Safe

  At Risk

  N/A

Line-of-Fire

• Body Position (falling, struck by, striking against, pinch point)

  Safe

  At Risk

  N/A

• PPE (required, adequate, good condition, worn properly)

  Safe

  At Risk

  N/A

• Guards, Barriers, LOTO

  Safe

  At Risk

  N/A

Ergonomics

• Lifting, Bending, Twisting

  Safe

  At Risk

  N/A

• Reaching, Pulling, Pushing (excessive force)

  Safe

  At Risk

  N/A

Standards

• Followed

  Safe

  At Risk

  N/A

• Orderliness (housekeeping, storage, access, OLA)

  Safe

  At Risk

  N/A

Tools & Equipment

• Proper tool for the job

  Safe

  At Risk

  N/A

• Good Condition

  Safe

  At Risk

  N/A

Recap

• Positive Feedback and Comments

• Additional Follow Up Required

• undefined