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Critical Behavior Checklist Template

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Critical Behavior Checklist Template

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Audit

Office Ergonomics

Upper back and neck

Lower back

Shoulders and Elbows

Typing / Mousing

Recognizing discomfort

Breaking up static posture

PPE

Eye / Face / Head / Hearing Protection

Hand Protection

Fall Protection

Clothing / Foot Protection

Respiratory Protection

Body Use and Position

Body Square to Task

Break-up / Rotate Repetitive Tasks

Focus on Task (hand / eye placement)

Pushing / Pulling Objects

Breaking Up Static Posture

Prolonged Standing (One Foot Forward)

Lifting

Knees Bent / Back Straight

Objects Close / Weight Test

"Build a Bridge"

Work Environment

Slip / Trip / Fall Hazard

Housekeeping / Material Storage

Barricades / Work Area Secured

Spill Prevention

Chemical / Flammable Hazards addressed

Tools & Equipment

Correct Tool Selection

Tool Use & Condition

Safety Guards in Place

Use of Lifting Equipment

Forklift / Manlift

Safety Belt / Harness in Place

Load Balanced / Stacks / Fork Position

Cones and Barricades in Place

Light Vehicle / Truck

Visual Pre-inspection Performed: signals, lights, horn

Seat Belts / Both Hands on Wheel

Looking 15 seconds Ahead

Following / Stopping Distances

Mirrors / Blind Spots

Eyes Moving Frequently / Relevant Objects

Space Cushion / Have an "Out"

Eye Contact / Proper Use of Signals / Horn

Reasons for At-Risk Behavior

A1 - disagrees with safe practice

A1 - Disagrees with safe practice

Thinks this way is safe

Disagrees with the observer on safe practice for the job

A2 - Personal Choice / Shortcuts

Aware of hazard but too rushed / extra work

Chooses to work at risk for medical reasons

Chooses to not spend money for PPE

Peers all do the job this wayA3

A3 - Job Knowledge

Unaware of safe practices for specific job

Unaware of risks associated with work location

Doesn't think a specific safe practice applies to the job

A4 - Job Focus

Lost focus, thinking about anything other than current task

A5 - Facilities / Equipment

Different Design of facilities or equipment needed

Proper tools or safety equipment not available

A6 - Management System

Leader supports doing the job this way

Leader disagrees with safe practice

Name and signature of observer

Date and time of completion

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