Behavior Based Safety Observation Form

Behavior Based Safety (BBS) Observation Form

6G MSI
Your concerns for safety and suggestions on how to improve our safety program are important to 6G MSI. Use this form to submit either safety improvement input and/or a BBS safety observation. Your name is optional and the name of the person being observed is not to be used. This information will be used to continually improve our safety program and working conditions.
Date

MonthDayYear
Date
BBS ObservationUnsafe ActUnsafe ConditionRecognitionEnvironmental
Location of Observation
Observer Name

First NameLast Name
Observer Email
example@example.com
Supervisor Name

First NameLast Name
Supervisor Email
example@example.com
Notes:
Describe in detail
Recommendation(s)
Describe in detail
Action Taken:
Describe in detail

PPE / Procedures / Methods

Body Position

Slips / Trips

Equipment / Work Environment

Behavior Based Safety (BBS) Observation Form