SAFETY SAFETY

BEHAVIOR OBSERVATION CHECKLIST BEHAVIOR OBSERVATION REPORT

"All field Project Management personnel shall CSBOR # :

complete this form weekly, as a minimum, and
retain in the project records".

Observe quietly. Mark each observation item:

N/A if Not Applicable

Stop Work
0 if Non-Compliant
1 if Needs Improvement
2 if Compliant

Contractor Area Supervisor's Company ID/Badge #:

1 . Personal Protective Equipment (PPE)
* Are employees wearing and properly
using approved PPE in good condition for :

Signature:

Signature:

Signature:
Head

Immediate Corrective Action(s) Taken:

Written

Record Corrective Actions Taken or

Ears
Eyes
Face
Contractor Safety Observation Report

Respiratory Protection
Contract/BI Number:

Hands
Observation Date:

Body

Verbal
Feet
2 . Positions of People
* Do contractor employees maintain safe positions
to prevent:
Falls

Badge #

Badge #

Badge #
Overexertion
(If yes, describe below)

Striking Against/Struck By
Caught Between Objects
Intake/Contact With Hazardous Substance
Contact With Hot/Cold Surface
Were Any Observations Considered Immediately Dangerous to

Contact With Electric Current

3 . Rules and Procedures
No

Procedures Developed
Procedures Known And Understood
Procedures Followed
Yes

Supervisor at Work Activity

Certified/Competent Work Activity Personnel
Work Permit Receiver and Valid Work Permit
Contractor Area Supervisor:

Approved Safety Officer on Site

4 . Tools and Equipment
Describe Key Observa
Life or Health (IDLH)?
Contractor Company:

Work Location Area:

Correct for the job

Contractor Name:

Project Engineer:
Observer Name:

Used Properly
Safe Condition
5 . Housekeeping
PQP
Good Housekeeping Maintained

Contractor Com

Work Location A

Contractor Area
Were Any Obser

Life or Health (ID

Describe Key Ob

Observer Name:

Contractor Nam

Project Enginee
T