Behaviour Based Safety Observation Form Z1
© 1Life Workplace Safety Solutions Ltd. 2016 Page 1 of 1
280 Stradbrook Ave, Winnipeg, MB R3L 0J6 www.1LifeWSS.com
ME
IR
ME
IR
PPE
PROCEDURE
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
ME – Meets expectations IR – Improvement Required
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 employee: (Yes / No)
Observer Sign:
Employee Sign:
Employee Observed:
Observer:
Date of Observation:
Location:
Task:
