Behavior Based Safety Form

BBS REV 3
Observer's Name*

First NameLast Name
Email*
example@example.com
Date*

MonthDayYear
Date
Time*

:HourMinutesAM/PM Option
Division:*
Yard:*
Company:
Lease:
Well Name or # :
Joint Observation with Customer? *
Customer Observer(s):

Name 1Name 2
Gravity services being provided:
Driver's License Expiration:*
All employees are required to have an ID
Medical Card Expiration:
DOT drivers only
Please select all categories that are UNSAFE:
Personal Protective Equipment (Hard Hat, Boots, Hearing Protection, Safety Glasses, FR Clothing, Gloves and H2S Monitor) :

Unsafe
Body Use & Positioning (Lifting, Pushing, Pulling, Ascending/ Descending, Overexertion):

Unsafe
Line-of-Fire (Housekeeping, Warning Devices, Barricades, Fire Extinguishers, Ventilation, Overcrowding):

Unsafe
Procedures (JSA, Hazard Identification, Work Permits):

Unsafe
Tools and Equipment (Tool Selection, Lifting Equipment, Machine Selection, Electrical Cables, Grounding):

Unsafe
LOTO:

Unsafe
Please describe in detail why an observation was deemed unsafe
Take Photo
Select a negative behavior observation:

RushingFrustrationFatigueComplacency
List any negative behavior comments:
Select any/ all Positive Behavior Observations:

PreparedCautiousCompetentStrong Communication
List any positive behaviors that should be recognized:
List any safety interventions, corrective actions:
Take Photo if needed
Should be Empty:

BBS REV 3