Behavior Based Safety

Observation Checklist
Observer Name: Observation Date: Location:
office field

Type: Positive Recognition: Address:

Self Other Yes No

States: Critical Errors: Check below if at risk or check to the right if no risk evident:

Rushing Not focused on task Tools and Equipment: Procedures:

Frustration Mind not on task Unsafe condition Procedures followed properly

Fatigue Not focused on details Inappropriate for task Procedures available and up to date

Complacency Other (describe) Capacity exceeded Worker aware of procedures

Other (describe)

Work Area: Humon Factors: PPE Needed:

Lifting, bending, twisting Hard Hat Hand Respiratory

Area Clean of Obstructions. Housekeeping

Hazardous materials labelled. Confined spaces Reaching, extending, pulling Eyes and face Body Fall

Walking under suspended loads. Pinch points Repetitive motion Hearing Foot Other (describe below)

Slip trip fall hazards Needs additional assistance Description:

Explain (What Happened?):

Corrective Actions:

Completed by Name: Signature: Date: