Assessment Phase Report

• Facility

• Address

• Contact/Title

• Phone

• Email

• SIC/NAICS

• Description of Operations

• Assessed by

• Date

  Date

Policies & Procedures

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

  Yes

  No

  N/A

Training

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are training records organized and easily retrieved?

  Yes

  No

  N/A

Incident Management

• Does the organization have a documented incident management process?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Recordkeeping

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Compliance

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Air Pollution Control

• Does the facility produce air emissions?

  Yes

  No

  N/A

• Are air emissions permitted?

  Yes

  No

  N/A

• Issuing Agency

• Permit ID

• Expiration Date

  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)?

  Yes

  No

  N/A

• Has the facility previously filed a Tier II Report?

  Yes

  No

  N/A

Spill Prevention

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are materials/wastes stored within secondary containment?

  Yes

  No

  N/A

• Are spill response materials readily available?

  Yes

  No

  N/A

Sanitary Wastewater

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

  Yes

  No

  N/A

• Is the discharge permitted?

  Yes

  No

  N/A

• Issuing Agency

• Permit ID

• Expiration Date

  Date

Industrial Wastewater

• Does the facility discharge industrial wastewater?

  Yes

  No

  N/A

• Is the discharge permitted?

  Yes

  No

  N/A

• Issuing Agency

• Permit ID

• Expiration Date

  Date

Stormwater Management

• Does the facility discharge stormwater?

  Yes

  No

  N/A

• Is the discharge permitted?

  Yes

  No

  N/A

• Issuing Agency

• Permit ID

• Expiration Date

  Date

• Is the discharge exempt?

  Yes

  No

  N/A

Waste Management

• Does the facility generate solid waste?

  Yes

  No

  N/A

• Has all waste been appropriately characterized?

  Yes

  No

  N/A

• Does the facility recycle, where possible?

  Yes

  No

  N/A

• Does the facility generate hazardous waste?

  Yes

  No

  N/A

• Is waste appropriately stored, labeled & contained?

  Yes

  No

  N/A

• EPA Hazardous Waste Generator ID

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

  Yes

  No

  N/A

• Is universal waste appropriately stored, labeled & contained?

  Yes

  No

  N/A

• Does the facility generate used oil?

  Yes

  No

  N/A

• Is used oil appropriately stored, labeled & contained?

  Yes

  No

  N/A

PCBs & Other Toxic Substances

• Does the facility have PCB transformers on-site?

  Yes

  No

  N/A

• Are PCB items marked with PCB labels?

  Yes

  No

  N/A

Bloodborne Pathogens 29 CFR 1910.1030

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

  Yes

  No

  N/A

• Does the organization have an Exposure Control Plan?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

• Do team members perform repair and maintenance on equipment?

  Yes

  No

  N/A

• Does the facility have established energy control procedures?

  Yes

  No

  N/A

Combustible Dust

• Are there combustible dust hazards present?

  Yes

  No

  N/A

Electrical 29 CFR 1910.303

• Are electrical hazards present?

  Yes

  No

  N/A

• Does the organization follow safety-related work practices?

  Yes

  No

  N/A

• Is electrical equipment free from recognized hazards?

  Yes

  No

  N/A

Exit Routes & Emergency Planning 29 CFR 1910 Subpart E

Exit Routes 29 CFR 1910.35 & 1910.36

• Is the number of exit routes adequate?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are exit doors unlocked?

  Yes

  No

  N/A

Emergency Action Plans 29 CFR 1910.38

• Does the organization have an emergency action plan?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

• Does the organization maintain an emergency alarm system?

  Yes

  No

  N/A

Fire Prevention Plans 29 CFR 1910.39

• Does the organization have an fire prevention plan?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Fire Protection 29 CFR 1910 Subpart L

Portable Fire Extinguishers 29 CFR 1910.157

• Is the facility equipped with portable fire extinguishers?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

• Are portable fire extinguishers visually inspected monthly?

  Yes

  No

  N/A

Automatic Sprinkler Systems 29 CFR 1910.159

• Is the facility equipped with an automatic sprinkler system?

  Yes

  No

  N/A

• Is the system main drain flow test performed annually?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

First Aid/CPR/AED 29 CFR 1910.151

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are supplies and equipment in satisfactory condition?

  Yes

  No

  N/A

Hand & Portable Power Tools 29 CFR 1910.242

• Do team members use hand & portable power tools?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Hazardous Materials 29 CFR 1910 Subpart H

• Does the facility store or use hazardous materials?

  Yes

  No

  N/A

Compressed Gases 29 CFR 1910.101

• Does the facility utilize compressed gases?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Can cylinders be visually inspected?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Flammable Liquids 29 CFR 1910.106

• Does the facility use/store flammable liquids?

  Yes

  No

  N/A

• Are materials stored in fire-resistant cabinets?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Spray Finishing using Flammable & Combustible Materials 29 CFR 1910.107

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

  Yes

  No

  N/A

• Is there a designated spray booth?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Hazard Communication 29 CFR 1910.1200

• Does the organization have an inventory of hazardous chemicals?

  Yes

  No

  N/A

• Does the organization have a written hazard communication program?

  Yes

  No

  N/A

• Does the program include a provision for labeling?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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).

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Noise 29 CFR 1910.95

• Are noise hazards present?

  Yes

  No

  N/A

• Has a noise assessment been performed?

  Yes

  No

  N/A

• Is a hearing conservation program in place?

  Yes

  No

  N/A

• Is hearing protection provided and utilized?

  Yes

  No

  N/A

Overhead & Gantry Cranes 29 CFR 1910.179

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Personal Protective Equipment 29 CFR Subpart I

• Has the organization performed a workplace hazard assessment?

  Yes

  No

  N/A

Eye & Face 29 CFR 1910.133

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are there options for prescription eye wear?

  Yes

  No

  N/A

Respiratory Protection 29 CFR 1910.134

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are affected team members medically cleared and fit tested?

  Yes

  No

  N/A

Head Protection 29 CFR 1910.135

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

  Yes

  No

  N/A

• Are hazard-specific protective helmets provided and utilized?

  Yes

  No

  N/A

Foot Protection 29 CFR 1910.136

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

  Yes

  No

  N/A

• Is hazard-specific protective footwear provided and utilized?

  Yes

  No

  N/A

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)

  Yes

  No

  N/A

• Is hazard-specific hand protection provided and utilized?

  Yes

  No

  N/A

Personal Fall Protection Systems 29 CFR 1910.140

• Is there a potential for injuries from a fall?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Is fall protection equipment inspected?

  Yes

  No

  N/A

Permit-Required Confined Space Entry 29 CFR 1910.146

• Does the organization have confined spaces?

  Yes

  No

  N/A

• Are confined spaces clearly identified?

  Yes

  No

  N/A

• Are team members authorized to enter confined spaces?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Is there a procedure for performing atmospheric testing?

  Yes

  No

  N/A

• Is there a procedure for responding to emergencies?

  Yes

  No

  N/A

Powered Industrial Trucks/Forklifts 29 CFR 1910.178

• Does the organization operate powered industrial trucks?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are units inspected and maintained as required?

  Yes

  No

  N/A

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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Ladders 29 CFR 1910.23

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Stairways 29 CFR 1910.25

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

  Yes

  No

  N/A

Dockboards 29 CFR 1910.26

• Are dockboards capable of supporting the maximum intended load?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are guardrail mid rails 21" above the surface?

  Yes

  No

  N/A

• Are toeboards in place to protect from falling objects?

  Yes

  No

  N/A

Welding, Cutting & Hot Work 29 CFR Subpart Q

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Is ventilation provided for general welding and cutting?

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

Federal Motor Carrier Safety Regulations 49 CFR Part 390

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

  Yes

  No

  N/A

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

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

  Yes

  No

  N/A

• Are self-propelled CMVs properly marked?

  Yes

  No

  N/A

• Does the carrier have a GPS tracking system?

  Yes

  No

  N/A

Drug & Alcohol 49 CFR Part 40

• Does the carrier have a drug & alcohol program?

  Yes

  No

  N/A

Qualifications of Drivers 49 CFR Part 391

Initial Driver Qualification Documents

• Driver's Application of Employment 49 CFR 391.21

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Ongoing Updates

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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))

  Yes

  No

  N/A

Hours of Service of Drivers 49 CFR Part 395

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Inspection, Repair, & Maintenance 49 CFR Part 396

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A