Title Page

  • Facility

  • Address

  • Contact/Title

  • Phone

  • Email

  • SIC/NAICS

  • Description of Operations

  • Assessed by

  • Date

Management Systems

Policies & Procedures

  • Does the organization have required documented policies and procedures for managing environmental, safety, and transportation compliance?

  • Does the organization have an incentive program for team members based on EHS metrics?

Training

  • Does the organization have a formal, documented initial training program?

  • Does the organization have a formal, documented refresher training program?

  • Are training records organized and easily retrieved?

Incident Management

  • Does the organization have a documented incident management process?

  • Does the process include close call/near miss reporting?

  • Does the process clearly identify root causes of the incident?

  • Are corrective actions assigned, resolved, and documented to prevent incident reoccurrence?

  • Does the organization have a return-to-work program for injured team members?

Recordkeeping

  • Does the organization have more ten (10) team members?

  • Are OSHA 300/300A documents for the last three (3) years available?

  • Are EMR worksheets for the last three (3) years available?

Compliance

  • Has the organization been visited/inspected by a regulatory agency in the last three (3) years?

  • Has the organization received a notice of violation/citation from a regulatory agency in the last three (3) years?

Environmental

Air Pollution Control

  • Does the facility produce air emissions?

  • Are air emissions permitted?

  • Issuing Agency

  • Permit ID

  • Expiration Date

  • Emission Unit(s)

  • Control Equipment

  • Emission Point(s)

Emergency Planning & Community Right-To-Know

  • Does the facility store hazardous chemicals (>10,000 pounds) or extremely hazardous substances (>RQ)?

  • Has the facility previously filed a Tier II Report?

Spill Prevention

  • Does the facility store hazardous materials/waste and/or petroleum products?

  • Does the facility store more than 1,320 gallons of oil above ground in containers 55 gallons or larger?

  • Does the facility have a Spill Prevention Control & Countermeasure (SPCC) Plan?

  • Are materials/wastes stored within secondary containment?

  • Are spill response materials readily available?

Sanitary Wastewater

  • Does the facility discharge sanitary waste to an on-site septic system?

  • Is the discharge permitted?

  • Issuing Agency

  • Permit ID

  • Expiration Date

Industrial Wastewater

  • Does the facility discharge industrial wastewater?

  • Is the discharge permitted?

  • Issuing Agency

  • Permit ID

  • Expiration Date

Stormwater Management

  • Does the facility discharge stormwater?

  • Is the discharge permitted?

  • Issuing Agency

  • Permit ID

  • Expiration Date

  • Is the discharge exempt?

Waste Management

  • Does the facility generate solid waste?

  • Has all waste been appropriately characterized?

  • Does the facility recycle, where possible?

  • Does the facility generate hazardous waste?

  • Is waste appropriately stored, labeled & contained?

  • EPA Hazardous Waste Generator ID

  • Does the facility generate universal waste? (aerosol cans, batteries, lamps, mercury-containing equipment)

  • Is universal waste appropriately stored, labeled & contained?

  • Does the facility generate used oil?

  • Is used oil appropriately stored, labeled & contained?

PCBs & Other Toxic Substances

  • Does the facility have PCB transformers on-site?

  • Are PCB items marked with PCB labels?

Safety

Bloodborne Pathogens 29 CFR 1910.1030

  • Is there an occupational exposure to blood or other potentially infectious materials?

  • Does the organization have an Exposure Control Plan?

  • Does the organization provide Hepatitis B vaccinations to team members?

Control of Hazardous Energy (Lockout/tagout) 29 CFR 1910.147

  • Do team members perform repair and maintenance on equipment?

  • Does the facility have established energy control procedures?

Combustible Dust

  • Are there combustible dust hazards present?

Electrical 29 CFR 1910.303

  • Are electrical hazards present?

  • Does the organization follow safety-related work practices?

  • Is electrical equipment free from recognized hazards?

Exit Routes & Emergency Planning 29 CFR 1910 Subpart E

Exit Routes 29 CFR 1910.35 & 1910.36

  • Is the number of exit routes adequate?

  • Do exit discharges lead directly outside or to a street, walkway, refuge area, public way, or open space with access to the outside?

  • Are exit doors unlocked?

Emergency Action Plans 29 CFR 1910.38

  • Does the organization have an emergency action plan?

  • Is the emergency action plan in writing and available for review? (required for more than 10 employees)

  • Does the plan include procedures for reporting an emergency, evacuation/shelter locations, operation of critical operations, employee accountability, rescue/medical duties, and employees designated for additional information?

  • Does the organization maintain an emergency alarm system?

Fire Prevention Plans 29 CFR 1910.39

  • Does the organization have an fire prevention plan?

  • Is the fire prevention plan in writing and available for review? (required for more than 10 employees)

Fire Protection 29 CFR 1910 Subpart L

Portable Fire Extinguishers 29 CFR 1910.157

  • Is the facility equipped with portable fire extinguishers?

  • Are portable fire extinguishers mounted, located, and identified so they are readily accessible to employees?

  • Are portable fire extinguishers selected and distributed based on the classes of anticipated workplace fires and on the size and degree of hazard which would affect their use?

  • Are portable fire extinguishers visually inspected monthly?

Automatic Sprinkler Systems 29 CFR 1910.159

  • Is the facility equipped with an automatic sprinkler system?

  • Is the system main drain flow test performed annually?

  • Is the inspector's test valve opened at least every two (2) years?

First Aid/CPR/AED 29 CFR 1910.151

  • Are team members trained and equipped to initiate first aid and/or life saving measures?

  • Are first aid supplies and/or AED units available for team member use?

  • Are supplies and equipment in satisfactory condition?

Hand & Portable Power Tools 29 CFR 1910.242

  • Do team members use hand & portable power tools?

  • Are tools and equipment in safe condition, including ones furnished by team members?

  • Is compressed air used for cleaning purposes? (If yes, must be reduced to less than 30 psi)

Hazardous Materials 29 CFR 1910 Subpart H

  • Does the facility store or use hazardous materials?

Compressed Gases 29 CFR 1910.101

  • Does the facility utilize compressed gases?

  • Are compressed gas cylinders in a safe condition (storage, usage)?

  • Can cylinders be visually inspected?

  • Are flammable and oxygen cylinders separated by 20' feet?

Flammable Liquids 29 CFR 1910.106

  • Does the facility use/store flammable liquids?

  • Are materials stored in fire-resistant cabinets?

  • Are cabinets limited to <60 gallons of Category 1, 2, or 3 flammable liquids or <120 gallons of Category 4?

  • Do portable containers (<5 gallons) have a flash-arresting screen, spring-closing lid, and spout cover?

Spray Finishing using Flammable & Combustible Materials 29 CFR 1910.107

  • Does the facility spray finish using flammable & combustible materials? 29 CFR 1910.107

  • Is there a designated spray booth?

  • Are filter pads/rolls disposed of in an approved manner?

Hazard Communication 29 CFR 1910.1200

  • Does the organization have an inventory of hazardous chemicals?

  • Does the organization have a written hazard communication program?

  • Does the program include a provision for labeling?

  • Does the program include a provision for maintaining safety data sheets (SDSs)?

  • Does the program include a provision for team member training?

Machine Guarding 29 CFR 1910.212

  • Does the organization operate machines with potential hazards? (point of operation, ingoing nip points, rotating parts, flying chips, sparks).

  • Are machines equipped with guarding to prevent injuries? (barrier guards, two-hand tripping devices, electronic safety devices)

  • Are machines designed for a fixed location securely anchored to prevent walking or moving?

Noise 29 CFR 1910.95

  • Are noise hazards present?

  • Has a noise assessment been performed?

  • Is a hearing conservation program in place?

  • Is hearing protection provided and utilized?

Overhead & Gantry Cranes 29 CFR 1910.179

  • Does the facility operate overhead cranes and/or hoists?

  • Is the equipment inspected frequently? (Daily to monthly)

  • Is the equipment inspected periodically? (1-12 months)

  • Is the rated load of each crane plainly marked on each side of the crane & legible from the ground or floor?

Personal Protective Equipment 29 CFR Subpart I

  • Has the organization performed a workplace hazard assessment?

Eye & Face 29 CFR 1910.133

  • Do eye/face hazards exist? (flying particles, molten metal, liquid chemicals, corrosives, potentially injurious light radiation)

  • Is hazard-specific eye/face protection provided and utilized?

  • Are there options for prescription eye wear?

Respiratory Protection 29 CFR 1910.134

  • Is there a potential for respiratory hazards? (harmful dusts, fogs, fumes, mists, gases, smokes, sprays, vapors)

  • Is hazard-specific respiratory protection equipment provided and utilized?

  • Are affected team members medically cleared and fit tested?

Head Protection 29 CFR 1910.135

  • Is there a potential for injury to the head from falling objects or strikes?

  • Are hazard-specific protective helmets provided and utilized?

Foot Protection 29 CFR 1910.136

  • Is there a potential for foot injuries? (falling or rolling objects, or objects piercing the sole)

  • Is hazard-specific protective footwear provided and utilized?

Hand Protection 29 CFR 1910.138

  • Is there a potential for hand injuries? (skin absorption, severe cuts/lacerations, abrasions, punctures, chemical/thermal burns, temperature extremes)

  • Is hazard-specific hand protection provided and utilized?

Personal Fall Protection Systems 29 CFR 1910.140

  • Is there a potential for injuries from a fall?

  • Is hazard-specific fall protection equipment provided and utilized?

  • Is fall protection equipment inspected?

Permit-Required Confined Space Entry 29 CFR 1910.146

  • Does the organization have confined spaces?

  • Are confined spaces clearly identified?

  • Are team members authorized to enter confined spaces?

  • Is there a confined space entry permit/pre-entry checklist?

  • Is there a procedure for performing atmospheric testing?

  • Is there a procedure for responding to emergencies?

Powered Industrial Trucks/Forklifts 29 CFR 1910.178

  • Does the organization operate powered industrial trucks?

  • Are units appropriate for the environments in which they operate?

  • Are units equipped with the necessary safety guards and equipment?

  • Are units inspected and maintained as required?

Walking & Working Surfaces 29 CFR 1910 Subpart D

  • Are all places of employment, passageways, storerooms, service rooms, and walking-working surfaces kept clean, orderly, and sanitary?

  • Are walking-working surfaces designed to support the maximum intended load?

  • Is there sufficient and safe means of access and egress to/from walking-working surfaces?

Ladders 29 CFR 1910.23

  • Are portable ladders in a safe condition and used as designed?

  • Are fixed ladders in a safe condition and used as designed?

  • Are mobile ladder stands in a safe condition and used as designed?

Stairways 29 CFR 1910.25

  • Are stairways in a safe condition and protected as required (handrails, stair rails, guardrails)?

Dockboards 29 CFR 1910.26

  • Are dockboards capable of supporting the maximum intended load?

  • Are dockboards put into service after 01/17/2017, designed, constructed, and maintained to prevent transfer vehicles from running off the edge?

Fall Protection & Falling Object Protection 29 CFR 1910.29

  • Are employees protected by a guardrail, safety net, or personal fall protection system from a four (4) foot fall?

  • Are guardrail top rails 42" (+/- 3") above the surface?

  • Are guardrail mid rails 21" above the surface?

  • Are toeboards in place to protect from falling objects?

Welding, Cutting & Hot Work 29 CFR Subpart Q

  • Are there welding, cutting, and hot work hazards present?

  • Are designated areas free of combustibles (35 feet) or otherwise protected by flameproof covers, shields, or barriers?

  • Is appropriate personal protective equipment (eye/face, hand, clothing) provided and utilized?

  • Is ventilation provided for general welding and cutting?

  • Are oxygen cylinders separated from fuel-gas cylinders or combustibles by 20' or a 5' high non-combustible barrier (>0.5 hour fire-resistance rating?

Motor Carrier

Federal Motor Carrier Safety Regulations 49 CFR Part 390

  • Is the operation subject to the requirements of Federal Motor Carrier Safety Administration (FMCSA)?

  • US DOT Number (attach most recent MCS-150 form)

  • Does the carrier have an accident register for the past three (3) years?

  • Are self-propelled CMVs properly marked?

  • Does the carrier have a GPS tracking system?

Drug & Alcohol 49 CFR Part 40

  • Does the carrier have a drug & alcohol program?

Qualifications of Drivers 49 CFR Part 391

Initial Driver Qualification Documents

  • Driver's Application of Employment 49 CFR 391.21

  • Driver's Road Test Certificate or Equivalent 49 CFR 391.31(e)

  • Inquiry to Previous Employers: Safety Performance History Record Request 49 CFR 391.23(a)(1) and (b)

  • Safety Performance History Records: Driver Correction or Rebuttal (if applicable) 49 CFR 391.23(i)(2) & (i)(3)

  • Inquiry To State Agencies for 3-Year Driving Record 49 CFR 391.23(a)(1)and(b)

  • Pre-Employment Drug and Alcohol Documents 49 CFR 40.25(j); 49 CFR 382.301

  • Entry-Level Driver Training Certificate 49 CFR 380.509(b)

Ongoing Updates

  • Inquiry To State Agencies for Driving Record – Annual 49 CFR 391.25 (a) & (c)

  • Review of Driving Record – Annual 49 CFR 391.25 (c) (2)

  • Medical Examination Report and Medical Examiner’s Certificate 49 CFR 391.43

  • Employer note verifying that medical examiner is listed on National Registry of Certified Medical Examiners — Non-CDL drivers: 49 CFR 391.51(b)(9)(i)); CDL drivers: 49 CFR 391.51(b)(9)(ii))

Hours of Service of Drivers 49 CFR Part 395

  • Does the carrier have a process to monitor hours of service?

  • Are records retained for a period of six (6) months?

Inspection, Repair, & Maintenance 49 CFR Part 396

  • Does the carrier have an inspection, repair, & maintenance program?

  • Are records retained for a period of one (1) year & for six (6) months after the vehicle leaves the carrier's control?

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.