QHSEOFFICE Behavior Based Safety Observation Checklist

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

If requested, was regular safety check completed (TBT, PTW, etc. )?

Housekeeping

• Aisles/Walkways kept clear?

  Safe

  At Risk

  N/A

• Work area kept organized?

  Safe

  At Risk

  N/A

• Housekeeping: spills, cords or other trips, trash/clutter, lighting, or Flammables

Personal Protective Equipment

• All appropriate equipment or gear worn correctly?

  Safe

  At Risk

  N/A

• PPE kept in good condition?

  Safe

  At Risk

  N/A

• Personal protective equipment: hand, body, eyes/face, head, foot, respiratory, fall protection, hearing protection, or FR clothing/gear

Working Position

• Body position

  Safe

  At Risk

  N/A

• Location in working environment

  Safe

  At Risk

  N/A

• Working Position: poor posture, over stretched, above shoulder, below knees, twisting, caught in between, struck by, working at heights greater than 4', floor or wall opening, unprotected work edge, or false ceiling or floor.

Tools and Equipment

• Appropriate tools or equipment being used?

  Safe

  At Risk

  N/A

• Tools or equipment being used correctly?

  Safe

  At Risk

  N/A

• Tools or equipment in good condition?

  Safe

  At Risk

  N/A

• Tools and equipment: ladders, power or hand tools

Safe behaviors observed-actions taken to encourage safe behavior

Unsafe behaviors observed-action taken to correct and prevent recurrence

Line of fire. Is the worker in the line of fire?

• Grinding or drilling operations creating flying objects or particles - goggles/face-shield. Heavy equipment movement in the area - operator aware of pedestrian? Around rigging operations - hand in pinch point not under equipment? Working in front of live electrical panel - NFPA70E PPE

Safety procedures

• Lock-out/Tag-out, Arc Flash, Hot Work Permit, Confined Space

  Safe

  At Risk

  N/A

• Add media

  Media

• Auditor signature

  Sign