Information
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Month/Year
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Prepared by
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Conducted on
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Hazard Classification:
Class (A) - Major - To be corrected Immediately
A condition or practice likely to cause permanent disability, loss of life or body and/or extensive loss of structure, equipment or material -
Class (B) - Serious - To be corrected within 24 hours
A condition or practice likely to cause injury or illness, resulting in temporary disability or property damage that is disruptive but not excessive -
Class (C) - Minor - To be placed on action plan
A condition or practice likely to cause minor, non-disabling injury or illness or non-disruptive property damage -
Fire Extinguisher Map
Hazardous Waste Storage
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Housekeeping (5S)
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Hazard Class
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Lighting
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Hazard Class
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Liquids (labeled & properly stored)
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Hazard Class
First Aid Room
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Housekeeping (5S)
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Hazard Class
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Lights
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Hazard Class
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Emergency Contact List Available
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Hazard Class
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Incident Report Forms Available
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Hazard Class
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Record Log (maintained?)
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Hazard Class
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AED System (green light)
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Hazard Class
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AED Battery Expiration Date (list date)
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Hazard Class
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AED Supply Contents (list)
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Hazard Class
Production First Aid Supplies
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First Aid Kit
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Flex Wrap Roll - 2
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Adhesive Tape - 1
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Burn Treatment - 1
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Eye Wash - 1
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Gauze Pads 2x2 - 10
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Gauze Pads 3x3 - 10
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Gauze Pads 4x4 - 50 (More gauze pads under sink - all sizes)
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Resuscitation Barrier - 1
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Iodine Wipes - 20
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Triangular Bandage - 2
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Finger Splint - 1
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Scissors - 1
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Hydrocortisone Cream - 10
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Eye Covering - 1
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Gauze Roll 2in - 2
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Gauze Roll 3in - 2
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Ear Plugs - 10
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Other
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Bloodborne Pathogen Kit (under sink) - 1
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Latex Gloves (near sink) - 20
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Wool Blanket (wall mount) - 1
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AED Device (check contents) - 1
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Vending Machine
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Tweezers/Splinter Out - 1
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Ice Packs - 10
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Adhesive Bandages 1x3 - 100
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Antacid - 50
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Triple Antibiotic Ointment - 20
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Antiseptic Wipes - 20
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Advil/Ibuprofen - 50
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Tylenol - 50
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Antihistamine Tablets - 50
Production Washrooms
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Housekeeping (5S)
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Hazard Class
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Lights
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Hazard Class
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Supplies
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Hazard Class
Production Janitor's Closet
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Housekeeping (5S)
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Hazard Class
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Lights
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Hazard Class
Fire Extinguishers
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11
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12
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13
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14
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15
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17
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18
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19
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31
Comments
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Addition Comments
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Name & Initials