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Safety Behavior Observation Form
1. Observer Name *
2. Staff identification number *
Unilever Employee
Contractor
Without 000
Enter Company Name if you are a contractor
3. Date and Time
4. Area *
Ageing 1
Ageing 2
Ageing 3
Ageing 4
Ageing 5
Air Compressor
Ammonia
BENHIL
BIGDRUM1
BIGDRUM2
BIGDRUM3
BULK
Ceiling Mixing
Ceilling-RMS
Ceilling-Utility
Cleaning Room
Cold Storage
CORN
Eng & PE Room-PH
General Produksi
GILF
GRAMBT1
GRAMBT2
GRAMBT3
GRAMRIA10
GRAMRIA14
GRAMRIA5
GRAMRIA6
GRAMRIA7
GRAMRIA8
GRAMRIA9
HWG 1 ( Mixing )
HWG 2 & 3 ( Utility )
Kantin
Leader Room-PH
LVMDB 1 & 2
MCC 1
MCC 2
MCC 3
MCC 4
Mixing
Mixing MOCHI
MOCHI
MV 1 & 2
NEWCUP
Office 1st Floor
Office 2nd Floor
Office 3rd Floor
Office Block
Office Cold Storage
Office Project
Palletizing
Perimeter ( Luar Pagar )
Puyuan
Quality
Rework Room
RMS / SS
ROTARY
Ruang Disposal
Security
TPS B3
TPS Sludge Cake & Produksi
Tunnel
Utility CS
Utility-PH
VENTURA
VERSALINE
Workshop Kontraktor
Workshop ULI
WTP
WWTP
Yard Service ( Dalam Pagar )
Zudek Mixing
5. Type of work being observed
Type:
Lain-lain
Hot Work
Working at Height
Lifting
Low Voltage
Medium Voltage
Confined Space
Excavation
Demolition
Radiography
Description:
6. Object/Name of person being observed *
7. Number of personnel
8. Response [RP]
Wearing personal protection
Change position of existing installation, workplace, or work behavior
Creating new work plan
Stopping the work
De-energizing power sources
Installing safety equipment
Prevention for spreading of Covid-19
9. Personal Protective Equipment [PPE]
Head protection
Breathing
Face protection
Safety belt
Safety shoes
Eye protection
Hand protection
Ear/hearing protection
Body protection
Covid-19 Medical mask
Covid-19 protective eyewear / face shield
10. Tools and Equipment [TE]
Damaged tools
Improper tools
11. Work Procedure and 5S [PO]
Not following the correct procedure
Lack of knowledge in correct procedure
Inadequate 5S standard
Unavailable procedure
12. Person's Position [PP]
Falling
Electric shock
Contacting extreme temperature
Inhaling extreme temperature
Contacting dangerous chemical materials
Lifting object beyond capability
Repetitive unsafe act
Unproper work position
Crash by object
Dangerous work
Trapped inside of, on top of, or between the object
13. Safe action/condition being observed
Safe ACT
Safe CONDITION
14. Unsafe action/condition being observed
Unsafe ACT
Unsafe CONDITION
15. Reason for unsafe action
Selection
Consciousness
RJA (Recognition, Judgment, Action)
Alertness
Illusion
Forgetfulness
Be paralyzed
Guess/prejudice
Short cut/omit
Physical condition
State of mind
Visual direction
16. Have you done a follow-up action when reporting this SBO?
Done
Not Done
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