SAFETY SAFETY

BEHAVIOR OBSERVATION CHECKLIST BEHAVIOR OBSERVATION REPORT

"All field Project Management personnel shall CSBOR # :

complete this form weekly, as a minimum, and

Stop Work
retain in the project records".

Contractor Area Supervisor's Company ID/Badge #:

Record Corrective Actions Taken or Requested:

Observe quietly. Mark each observation item:
N/A if Not Applicable
0 if Non-Compliant
1 if Needs Improvement
2 if Compliant

Immediate Corrective Action(s) Taken:

1 . Personal Protective Equipment (PPE) * Are
employees wearing and properly using

Written
approved PPE in good condition for :
Head

Signature:

Signature:

Signature:
Ears
Eyes Contractor Safety Observation
Face

Verbal
Respiratory Protection
Hands
Contract/BI Number:

Body
Observation Date:

Feet
2 . Positions of People
* Do contractor employees maintain safe positions
Report

to prevent:
Falls
Overexertion

Badge #

Badge #

Badge #
Striking Against/Struck By
(If yes, describe below)

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
Procedures Developed
No

Procedures Known And Understood

Procedures Followed
Supervisor at Work Activity
Yes

Certified/Competent Work Activity

Personnel
Work Permit Receiver and Valid Work
Permit
Life or Health (IDLH)?

Approved Safety Officer on Site

Contractor Area Supervisor:

Describe Key Observations:

4 . Tools and Equipment

Contractor Company:

Work Location Area:

Correct for the job

Contractor Name:

Project Engineer:
Observer Name:

Used Properly
Safe Condition
5 . Housekeeping
Good Housekeeping Maintained
PQP