Behavior-Based Safety Observation Form
ReconAfrica
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location
Task Being Observed
Name of Observer (optional)
First Name
Last Name
Email
example@example.com
Planning
Rows
Safe
Needs Improvement
Tasks identified
Hazards associated with tasks identified
Hazard controls implemented
Plan documented
Observer’s feedback given to observed employee
PPE / Procedures / Methods
Rows
Safe
Needs Improvement
Eye & Head
Hand & Body
Footwear
Atmospheric Monitoring
Respiratory Protection
Trained on Task
Work Permit / JSA
All trained in BBS
Other
Observer’s feedback given to observed employee
Body Position / Mechanics
Rows
Safe
Needs Improvement
Proper Position
Ask for Help
Use Dolly
Bend knees
Smaller Loads
Don’t Twist Body
Other
Observer’s feedback given to observed employee
Slips / Trips
Rows
Safe
Needs Improvement
Proper Footwear
Aware of Hazards
Prompt Clean Up
Tripping Hazards
Not Rushing
Step Conditions
Other
Observer’s feedback given to observed employee
Equipment / Work Environment
Rows
Safe
Needs Improvement
MSDS If Needed
Lock Out
Tools are Safe
Adjacent Work
Signage if Needed
Spill Control
Other
Print Form
Save
Submit
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