Behavior-Based Safety Observation Form
Document and report observed safety behaviors in the workplace to promote a safer environment.
Observer Full Name
*
First Name
Last Name
Observation Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Department or Area Observed
*
Please Select
Production Floor
Warehouse
Office
Maintenance Area
Loading Dock
Other
Observed Person's Name (if applicable)
First Name
Last Name
Type of Behavior Observed
*
Safe Behavior
Unsafe Behavior
Specific Behaviors Observed
*
Rows
Observed
Not Observed
Proper use of personal protective equipment (PPE)
1
2
Following lockout/tagout procedures
3
4
Safe lifting techniques
5
6
Housekeeping and cleanliness
7
8
Proper use of tools and equipment
9
10
Following posted safety signs and instructions
11
12
Description of the Behavior (please provide details)
*
Contributing Factors (select all that apply)
Lack of training
Complacency
Inadequate supervision
Time pressure
Environmental conditions
Other
Suggested Corrective Actions or Recommendations
Overall Safety Compliance Rating
*
1
2
3
4
5
Additional Comments or Follow-Up Notes
Submit Observation
Should be Empty: