Information

Safety and Health Assessment Program Evaluation (SHAPE)

Company Name

Type of Visit

Status

Retro Group

  • Safety Review Visit Conducted by:

Follow Up Scheduled:

  • Follow up scheduled (if Applicable):

General Information

Number of Employees:

Contact Name

Email

Wisha Poster (WAC 296-800-200)

  • 1.) Does the employer have posters dated 12-2012?

  • 1a.) Notice to employees-If a Job Injury Occurs (F242-191-909)

  • 1b.) Job Safety and Health Law (F416-081-909)

  • 1c.) Your Rights as a Worker (F700-074-909)

Accident Prevention Program (WAC 296-155-110)

  • 2.) Is there an effective and practical ACCIDENT PREVENTION PLAN Present?

  • 2a.) A description of the employer total safety and health plan?

  • 2b.) An orientation showing employees what they need to know to perform their initial job assignments safely?

  • 2c.) How and when to report on the job injuries and the location of first aid facilities?

  • 2d.) How to report unsafe conditions?

  • 2e.) The use and care of personal protective equipment (PPE)?

  • 2f.) What to do in an emergency, including exit routes?

  • 2g.) Identification of hazardous gases,chemical, or materials used on-the-job and instructions on safe use emergency actions to take in the event of an accident exposure?

Safety Committee/Meetings (WAC 296-800-13025)

  • 3.) Is there an established Safety Committee?

  • 3a.) Did the employer with 11 or more employees establish a safety committee that meets at least monthly?

  • 4.) Is there established weekly safety meeting?

  • 4a.) Does the employer conduct at least monthly safety meetings (weekly on job sites)?

Weekly Inspections (construction) (WAC 296-155-110)

  • 5.) Is the company completing walk around inspections at the beginning and at least weekly on every job? (construction)

OSHA 300 LOG

  • 6.) Does company keep an OSHA 300 LOG

Personal Protective Equipment (WAC 206-800-160)

  • 7.) Has a hazard assessment been conducted?

  • 8.) Is there an effective written PPE Program?

  • 8a.) Are the employees trained?

Lockout/Tagout Control of Hazardous energy (WAC 296-803)

  • 9.) Is there a written LO/TO Program

  • 9a.) Are the employees trained?

First-Aid and CPR (WAC 296-155-120)

  • 10.) Are First-Aid kits available on every job?

  • 10a.) Are effective first-aid supplies available?

  • 11.) Does the company have valid CPR/First Aid trained employees?

Hazard Communication Program (WAC 296-155-17613)

  • 12.) Is there a written HAZCOM Program?

  • 12a.) Are employees trained?

  • 12b.) Is training documented?

  • 13.) Is there an MSDS

  • 13a.) Do employees have reasonable access?

Hearing Conservation (WAC 296-155-145)

  • 14.) Is there a written hearing conservation plan?

  • 14a.) Are employees trained?

Permit Required Confined Space Program (WAC 296-809)

  • 15.) Has the employer evaluated the workplace to determine if confined spaces are present?

  • 16.) Is there a Written Confined Space Program?

  • 16a.) Are employees trained?

Respiratory Protection (WAC 296-155-17613)

  • 17.) Has the employer conducted a Hazard Assessment

  • 18.) Is there a written Respirator Protection Program?

  • 18a.) Are employees trained in the RPP?

  • 18b.) Were medical evaluations and questionnaires administered?

  • 18c.) Were qualitative FIT tests performed?

Fall Protection (WAC 296-155 Part C-1 Construction) (296-800 General Industry)

  • 19.) Has employer conducted a hazard assessment

  • 20.) Is there a Written Fall Protection Plan?

  • 20a.) Are employees trained?

Welding and Cutting (WAC 296-155-400 thru WAC 296-155-420)

  • 21.) Does company have a Hot Work program established?

  • 21a.) Are employees trained?

MISC TOPICS

  • 22.) Does company conduct new hire orientation?

  • 23.) Does company have an employee discipline program?

Comments

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.