Behaviour Based Safety Observation Form -Z1

Date of Observation: Observer:

Employee Observed: Location: Task:
ME – Meets expectations IR – Improvement Required
PPE ME IR PROCEDURE ME IR
PPE worn_________________________ Established and understood
Meets job requirements Employee authorized to operate
Worn correctly Maintained and followed
Acceptable condition Adequate for task

TOOLS / EQUIPMENT HOUSEKEEPING

Tools/equipment Area is clear of obstructions
Safe tools, equipment, material Area is used for its intended purpose
Proper guards, barriers Material is stored in safe manner
Used correctly Proper disposal procedures followed

PEOPLE CHEMICALS
Exertion: pushing / pulling / lifting / reaching MSDS available
Extreme temperatures: pushing / pulling Chemicals are stored appropriately
Risk to be struck by objects Correct PPE is worn around chemicals

Observers Notes:

Corrective Action Required:

Observers Feedback given to Employee:

Observer Signature: Date:

Employee Observed Signature: Date

Internal Use:
Documented for trend analysis Yes No
Feedback given to observed Observer Sign Employee Sign
employee

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