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1
Date
*
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Date
Month
Day
Year
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2
The Type of Assessment
*
This field is required.
BBS Self Evaluation
BBS Coworker Observation
BBS Third Party Observation
Hazard Identification
Suggestion Box
BBS Self Evaluation
BBS Coworker Observation
BBS Third Party Observation
Hazard Identification
Suggestion Box
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3
Employee ID# and Name
*
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Employee ID #
Employee Name
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4
Facility
*
This field is required.
60TTB
60TTW
61BR
62WC
63CF
64BA
64BW
64RD
64RT
65BN
65CG
65CL
65WT
66SG
67LT
67PH
67SC
67SH
67SJ
67WI
68AL
68BL
68DR
68GM
68LG
68SW
69AG
69DE
69EL
69KP
69DU
72SYQ
75URR
75UWW
76ENU
76EPN
76ESW
76ETO
76ETW
77CLA
77CRR
77DNR
77DOR
77EAS
77ERB
77ERL
77ERM
77ERN
77ERR
77EVG
77GVN
77LER
77FAL
77LIN
77MPO
77OIC
77RMO
77ROP
77RPO
77SAA
77SCA
77SMR
78TLN
83MHR
84MCL
84MDQ
84MFJ
84MFK
84MHT
84MLA
84MLB
84MLC
84MOY
84MPA
84MPZ
90DB
90DL
90DTR
90GL
90LB
90LR
90MA
90RA
90RY
90SI
90SQ
90WN
97BBL
97BCV
97BPO
97BRA
97BRE
97BRD
97BRI
97BRL
97BRP
97BRR
97BSM
97CBR
97DTR
98MKU
921D
922D
923D
ADC
AVD
BDC
BGT
BOO
BRN
CDC
DND
DOD
KLD
LED
LFD
LND
LPD
MAA/MPD
MAB/MPP
MAD
MAE
MAF
MAG
MAJ
MAL
MBD
MBE
MBF
MBG
MBH
MBS
MCD
MCE
MCH
MCJ
MCO
MDE/MPE
MDG
MDI/MDA
MEV
MFA
MFB
MFC
MFF
MGA/MPL
MGB
MGC
MGD
MHA
MHD
MHE
MHF
MHG
MHI/MPF
MHM
MHS
MKA
MKH
MKR
MLS
MOA/MPG
MOB/10T01/MPH
MOC
MOD
MOE/MPM
MOF/MPJ
MOK
MOL
MOM
MON
MOO
MOZ
MRE
MRF
MRH
MWM
MZA
MZB
MZC
MZD
MZJ
MZQ
MZR
MZV
ODC
ONT
PHD
RCD
SDC
SPE
SPG
TDC
VIP/MVP
60TTB
60TTW
61BR
62WC
63CF
64BA
64BW
64RD
64RT
65BN
65CG
65CL
65WT
66SG
67LT
67PH
67SC
67SH
67SJ
67WI
68AL
68BL
68DR
68GM
68LG
68SW
69AG
69DE
69EL
69KP
69DU
72SYQ
75URR
75UWW
76ENU
76EPN
76ESW
76ETO
76ETW
77CLA
77CRR
77DNR
77DOR
77EAS
77ERB
77ERL
77ERM
77ERN
77ERR
77EVG
77GVN
77LER
77FAL
77LIN
77MPO
77OIC
77RMO
77ROP
77RPO
77SAA
77SCA
77SMR
78TLN
83MHR
84MCL
84MDQ
84MFJ
84MFK
84MHT
84MLA
84MLB
84MLC
84MOY
84MPA
84MPZ
90DB
90DL
90DTR
90GL
90LB
90LR
90MA
90RA
90RY
90SI
90SQ
90WN
97BBL
97BCV
97BPO
97BRA
97BRE
97BRD
97BRI
97BRL
97BRP
97BRR
97BSM
97CBR
97DTR
98MKU
921D
922D
923D
ADC
AVD
BDC
BGT
BOO
BRN
CDC
DND
DOD
KLD
LED
LFD
LND
LPD
MAA/MPD
MAB/MPP
MAD
MAE
MAF
MAG
MAJ
MAL
MBD
MBE
MBF
MBG
MBH
MBS
MCD
MCE
MCH
MCJ
MCO
MDE/MPE
MDG
MDI/MDA
MEV
MFA
MFB
MFC
MFF
MGA/MPL
MGB
MGC
MGD
MHA
MHD
MHE
MHF
MHG
MHI/MPF
MHM
MHS
MKA
MKH
MKR
MLS
MOA/MPG
MOB/10T01/MPH
MOC
MOD
MOE/MPM
MOF/MPJ
MOK
MOL
MOM
MON
MOO
MOZ
MRE
MRF
MRH
MWM
MZA
MZB
MZC
MZD
MZJ
MZQ
MZR
MZV
ODC
ONT
PHD
RCD
SDC
SPE
SPG
TDC
VIP/MVP
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5
Job Task
*
This field is required.
Please select job task.
Please Select
Other
Blending Product Formulations
Box Vans-Moving / Staging
Box Vans-Unloading
Box Vans-Loading
Compatibility Testing
Drum-Dumping
Drum-Dumping
Drum-Pumping
Drum-Sampling
Drum-Shredding
Empty Drum-Crushing
Empty Drum-Loading
Fuel Blending
INCIN-Container Drop
INCIN-Direct Injection Bulk
INCIN-Direct Injection Drum
INCIN-Repacking
LF- Cell compaction and cover
LF- Leachate Sampling
LF- Transfer
LAND FARM-Disc / Injecting
LAND FARM-Wheel Wash
Mnt-Pump Repair
Mnt-LDAR Monitoring
Mnt-Welding
Oder Picking
Powered Industrial Vehicle (forklift) Operations
Rail Tank Car-Unloading
Rail Tank Car-Loading
Rail Tank Car-Moving
Rail Tank Car-Sampling
RC-Column Operation
RC-Decanting
RC-Dryer
RC-Distillation Operation
RC-Salting
Solidification
Stabilization
Stretch Wrapping Operation
Tankers-Moving / Staging
Tanker-Sampling
Tanker Loading
Tanker Unloading
UMO-Oil Filter Collection
UMO-Emulsion Breaking: UMO-Barge Loading
UMO-Barge Unloading
OPB -Line Filler
OPB-Product Blending
OPB -Tanker Compartment Filling
Permit Work Activities
WWT- Inorganic Treatment
WWT-Batch Reactor
WWT-Filter Press Operations
Please Select
Please Select
Other
Blending Product Formulations
Box Vans-Moving / Staging
Box Vans-Unloading
Box Vans-Loading
Compatibility Testing
Drum-Dumping
Drum-Dumping
Drum-Pumping
Drum-Sampling
Drum-Shredding
Empty Drum-Crushing
Empty Drum-Loading
Fuel Blending
INCIN-Container Drop
INCIN-Direct Injection Bulk
INCIN-Direct Injection Drum
INCIN-Repacking
LF- Cell compaction and cover
LF- Leachate Sampling
LF- Transfer
LAND FARM-Disc / Injecting
LAND FARM-Wheel Wash
Mnt-Pump Repair
Mnt-LDAR Monitoring
Mnt-Welding
Oder Picking
Powered Industrial Vehicle (forklift) Operations
Rail Tank Car-Unloading
Rail Tank Car-Loading
Rail Tank Car-Moving
Rail Tank Car-Sampling
RC-Column Operation
RC-Decanting
RC-Dryer
RC-Distillation Operation
RC-Salting
Solidification
Stabilization
Stretch Wrapping Operation
Tankers-Moving / Staging
Tanker-Sampling
Tanker Loading
Tanker Unloading
UMO-Oil Filter Collection
UMO-Emulsion Breaking: UMO-Barge Loading
UMO-Barge Unloading
OPB -Line Filler
OPB-Product Blending
OPB -Tanker Compartment Filling
Permit Work Activities
WWT- Inorganic Treatment
WWT-Batch Reactor
WWT-Filter Press Operations
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6
Task
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7
Area
*
This field is required.
Identify location of Plant issue observed
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8
Identify Contractor / Driver / Transporter / Vendor
*
This field is required.
Identify Company not individual
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9
Event Description
*
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Enter brief description of event.
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10
Detailed Description of Event
*
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Enter detailed description of event.
Huge
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Normal
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Ok
quote
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11
Hazards Identified
*
This field is required.
None
Environmental Concern
Safety Concern
House Keeping Concern
Maintenance Concern
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12
Type of Safety Concern Identified
*
This field is required.
Identify area(s) of concern or if None enter None: All Safe
Tools & Equipment
Procedure
PPE
Unsafe Act
Unsafe Condition
None: All Safe
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13
TOOLS & EQUIPMENT
*
This field is required.
Do I have the tools and equipment to safely perform task?
Yes
No
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14
What is the issue with tool or equipment selected?
*
This field is required.
No Tool /Equipment provided.
Incorrect tool/ equipment for job.
Tool being used improperly.
Tool is damaged or defective.
Tools or Equipment not being used.
No Tool /Equipment provided.
Incorrect tool/ equipment for job.
Tool being used improperly.
Tool is damaged or defective.
Tools or Equipment not being used.
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15
Additional description about tool & equipment and corrective action taken
*
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16
PROCEDURE
*
This field is required.
For routine work, I have been trained on procedure associated JHA and will follow the procedure or for non-routine work the JHA/JSB has been completed, permits issued and work group has reviewed material and are working within limits of permits or JHA?
Yes
No
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17
What is the issue with procedure?
*
This field is required.
Employee is not familiar with SOP.
SOP not in place.
SOP / JHA not in place.
JHA not in place.
SOP is not being followed.
JHA/JSB has not been completed.
Information on JHA/JSA or permits is incomplete.
JHA/JSB and or Permits have not been reviewed with entire work group
Employee is not familiar with SOP.
SOP not in place.
SOP / JHA not in place.
JHA not in place.
SOP is not being followed.
JHA/JSB has not been completed.
Information on JHA/JSA or permits is incomplete.
JHA/JSB and or Permits have not been reviewed with entire work group
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18
Additional detail about procedure and corrective action taken
*
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19
PPE
*
This field is required.
I have the correct PPE to complete the task?
Yes
No
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20
Identify Issue with PPE
*
This field is required.
Not Used
Not Used Properly
Wrong Selection
Improper Fit
Head Protection
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Eye / Face Protection
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Hearing Protection
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Respiratory Protection
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Hand Protection
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Torso Protection
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Foot Protection
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Leg protection
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Arm Protection
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Head Protection
Eye / Face Protection
Hearing Protection
Respiratory Protection
Hand Protection
Torso Protection
Foot Protection
Leg protection
Arm Protection
Not Used
Row 0, Column 0
Not Used Properly
Row 0, Column 1
Wrong Selection
Row 0, Column 2
Improper Fit
Row 0, Column 3
Not Used
Row 1, Column 0
Not Used Properly
Row 1, Column 1
Wrong Selection
Row 1, Column 2
Improper Fit
Row 1, Column 3
Not Used
Row 2, Column 0
Not Used Properly
Row 2, Column 1
Wrong Selection
Row 2, Column 2
Improper Fit
Row 2, Column 3
Not Used
Row 3, Column 0
Not Used Properly
Row 3, Column 1
Wrong Selection
Row 3, Column 2
Improper Fit
Row 3, Column 3
Not Used
Row 4, Column 0
Not Used Properly
Row 4, Column 1
Wrong Selection
Row 4, Column 2
Improper Fit
Row 4, Column 3
Not Used
Row 5, Column 0
Not Used Properly
Row 5, Column 1
Wrong Selection
Row 5, Column 2
Improper Fit
Row 5, Column 3
Not Used
Row 6, Column 0
Not Used Properly
Row 6, Column 1
Wrong Selection
Row 6, Column 2
Improper Fit
Row 6, Column 3
Not Used
Row 7, Column 0
Not Used Properly
Row 7, Column 1
Wrong Selection
Row 7, Column 2
Improper Fit
Row 7, Column 3
Not Used
Row 8, Column 0
Not Used Properly
Row 8, Column 1
Wrong Selection
Row 8, Column 2
Improper Fit
Row 8, Column 3
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21
Additional detail about PPE and corrective action taken
*
This field is required.
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22
UNSAFE ACT
*
This field is required.
I have thought about line of fire, body positioning and safe work practices for this job? I have considered the following: * Am I in the line of moving equipment? * Am I underneath equipment that could fall? * Is something under tension nearby?
Yes
No
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23
Description of Unsafe Act
*
This field is required.
Unauthorized operation or use of equipment
Poor housekeeping
Removing or bypassing safety devices
Failure to use safety devices
Failure to warn or signal
Unsafe Awkward body position
Body in line of fire
Risk of Striking Against
Exposure to electrical current
Improper lifting techniques
Speeding
Failure to obey safety sign
Using Equipment Improperly
Horseplay
Bypass Safety Devices
Using Defective Equipment
Failure to Secure
Failure to Check/Monitor
Failure to React/Correct
Failure to Identify Hazard/Risk
Improper Loading
Employee show signs of impairment (Slurred speech, poor coordination, trouble keeping balance)
Other
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24
Additional Description Unsafe Act and corrective action
*
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25
UNSAFE CONDITION
*
This field is required.
I have surveyed area for Unsafe Condition?
Yes
No
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26
Description of Unsafe Condition
*
This field is required.
Inadequate guards
Inadequate safety devices/interlocks
Inadequate alarm / warning system
Protruding object hazards
Inadequate or excess illumination
Intense noise.
Slip/Trip Hazards
Open electrical system/ exposed wires
Inadequate Hazard Communication (unmarked piping / tanks, Warning signs)
Inadequate Ventilation
Energy Control Hazard; Electrical, Chemical, Heat, Radiation, Mechanical, Potential
Atmospheric Hazards (Flammable, Toxic, O2 deficient)
Weather Extremes or Conditions
Road Conditions
Natural Hazard (Poison Oak, Poison Ivy, Spiders, Bees, Ants, Snake)
Other
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27
Take Photo of unsafe Condition
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28
Additional description of unsafe condition and corrective action
*
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29
What was the environmental concern?
*
This field is required.
Release to environment-Air
Release to environment-Ground
Release to environment-Water
Storm Water Structural Control Needed
Storm Water Structural Control in poor condition
Site Generated Waste in container not marked and labeled or properly labeled
Site Generated Waste in container label not legible
Site Generated Waste container not closed
PPE placed in regular trash
other
Release to environment-Air
Release to environment-Ground
Release to environment-Water
Storm Water Structural Control Needed
Storm Water Structural Control in poor condition
Site Generated Waste in container not marked and labeled or properly labeled
Site Generated Waste in container label not legible
Site Generated Waste container not closed
PPE placed in regular trash
other
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30
Identify other environmental concern
*
This field is required.
Give a brief description of concern
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31
What was the corrective action of environmental concern?
*
This field is required.
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32
What is the Housekeeping Concern
*
This field is required.
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33
What was the corrective action of housekeeping concern?
*
This field is required.
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34
What is the maintenance concern?
*
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35
What was corrective action of maintenance concern?
*
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36
Observer Email
*
This field is required.
Enter your e-mail
example@example.com
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37
Supervisor Email
*
This field is required.
Enter supervisor e-mail to notify of corrective action
example@example.com
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38
Were all issue resolved at completion of this observation?
YES
NO
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39
Description of what was observed
*
This field is required.
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40
Do you want to recognize employee for doing an exceptional job
*
This field is required.
YES
NO
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41
Please provide employee name.
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42
What could be done to improve task or procedure?
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