BBS Observation Form

Behavior Based Safety - Observation & Intervention Program

Step 1 of 9 — Observer Identification

Observer Identification

Observer Type *

Internal (NFS Staff) External (Visitor)

Select Staff Member *

Your Company *

Badge Number *

Department *

Observation Date *

Day of Week

Time of Day *

AM PM Friday Night

Manager Accompanied *

Observation Context

Activity Observed *

Craft Observed *

Area Visited *

Working Condition *

Organization Observed *

Was the observation stopped?

Yes No

Was intervention required?

Yes No

Procedures

Rate each item: Safe At Risk Unseen N/A

Item	Safeselect all	At Riskselect all	Unseenselect all	N/Aselect all
Permit to work
Following safe work procedures
Task Instruction
LMRA (Last Minute Risk Assessment)

Position of Body

Rate each item: Safe At Risk Unseen N/A

Item	Safeselect all	At Riskselect all	Unseenselect all	N/Aselect all
Line of Fire
Attention / keep eyes on task or on path
Working position
Stabilized surface
Lifting / pulling / pushing / carrying
Ascending / descending

Use of PPE

Rate each item: Safe At Risk Unseen N/A

Item	Safeselect all	At Riskselect all	Unseenselect all	N/Aselect all
Hand & arm protection
Eyes & face protection
Ears protection
Head protection
Respiratory protection
Foot & leg protection
Work clothes
Gas detectors
Water flask
Fall protection & Anchor point

Tools & Equipment Use

Rate each item: Safe At Risk Unseen N/A

Item	Safeselect all	At Riskselect all	Unseenselect all	N/Aselect all
Suitable for job
Used correctly
In safe condition
De-energizing / isolating / securing equipment

Housekeeping / Work Environment

Rate each item: Safe At Risk Unseen N/A

Item	Safeselect all	At Riskselect all	Unseenselect all	N/Aselect all
Material storage
Spill management
Cables, cords & hoses
Waste disposal
Tidiness & cleanliness
Dust management
Barricade & warnings
Access & egress

Welfare

Item	Safeselect all	At Riskselect all	Unseenselect all	N/Aselect all
Toilets
Rest shelter
Cooling shelter
Smoking shelter
Pray room
Water dispenser

Review & Submit

Please review your observation before submitting.

Observer Information

Observation Context

Ratings Summary

Feedback & Barriers

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