BC Ambulance Service Station Safety Inspection

• Conducted on

  Date

• Station # / Location

• Inspection # (yr-op-##)

• Inspectors have reviewed previous inspection report:

• YES, previous inspection reports reviewed.

• NO, previous inspection reports not reviewed:

• If no, explain:

Inspection Template Information

• Hazard Legend:
  
  Type A Hazard: Imminent hazard that requires correction IMMEDIATELY
  Type B Hazard: Urgent situation that requires correction ASAP
  Type C Hazard: Non emergent hazard that needs correction WITHOUT DELAY

• Reporting a safety hazard to WSI (A, B, C)
  
  - Call 1-877-222-3112 (press 1 if urgent issue)
  - Document description of issue
  - Record Service Due Date
  - Document work order number
  - Unit Chief to follow progress

• Reporting Info:
  
  - Please document any hazards and action taken on "Summary" page
  - When completed, select "export"
  - Select "PDF" and "email"
  - Report should me emailed to the station UC and Darlene.Clayton@bcehs.ca
  

• A1. Aisles clear

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• A2. Bay doors complete with working safety bars

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• A3. Bay door manual mechanism working

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• A4. Drains maintained

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• A5. Drop cords secure and pigtails (18" from floor)

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• A6. Fire extinguishers by exits (dated)

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• A7. Floors (non slip) maintained

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• A8. Furnace room (clean and tidy)

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• A9. Ground faults working/ checked

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• A10. No vehicle oil/ fluids found

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• A11. Entonox storage- secure/ decal

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• A12. Oxygen storage- secure/ decal

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• A13. Oxygen storage (away from combustibles)

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• A14. Main oxygen upright- valve caps/ secure

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• A15. Segregation of incompatible material

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• A16. Exhaust ventilation system working

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• A17. Stairs (if applicable) clear and well lit

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• A18. Hand rails secure

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• A19. Switch/ plugs with covert plates

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• A20. Tire storage low to ground

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• A21. Eyewash station (bottle full; mounted near sink)

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• B1. MSDS sheets in binder (complete, current)

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• B2. WHMIS books

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• B3. BCAS OSH Program manual

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• B4. Safety Bulletin board

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• B5. Copy of WCB regulations

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• B6. Employee immunization records

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• B7. Employee safety training tracking

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• B8. Fleet management bulletin manual

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• B9. Latest inspection posted

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• B10. Minutes posted - DOSH committee (last 3 months)

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• B11. Safe work procedures (posted/ filed)

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• B12. Reporting forms (1130A, 2414, 2339, 2340, WCB)

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• B13. Any asbestos listed/ marked

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• C1. Electrical panel accessible

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• C2. Electrical cords/ phone cords

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• C3. Emergency lights

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• C4. Fire extinguishers (dated) by exits

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• C5. Floors maintained (non slip wax)

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• C6. Furniture maintained

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• C7. Handrails and stairwells illuminated

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• C8. Smoke/ heat detectors

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• D1. Exterior lighting

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• D2. Snow/ ice removal procedure

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• D3. Structure appears in good shape

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• D4. Walkways clear/ lighted

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• E1. Clean/ orderly

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• E2. No heavy storage over 6 feet

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• E3. Shelving bolted to walls

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• F1. Lockers secure

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• F2. Separate storage of flammables

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• F3. Shelving secure

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• F4. Spare spineboard(s) in good order

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• F5. Stability of stored material

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• F6. Storage of hazardous products

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  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• G1. Electrical connectors

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  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• G2. Electrical wires/ fixtures

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  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

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• Service Due Date

  Date

• G3. General housekeeping & cleanliness

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  • Standard Met
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  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• G4. No tripping hazards

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  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• G5. Outlet cover plates where required

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  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• G6. Emergency exits with closures, marked/ visible

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  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• G7. Fire evacuation procedures in place

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  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• G8. Access/ egress unobstructed

  Select Standard Met Needs Improve Hazard A Hazard B Hazard C Online N/A

  • Standard Met
  • Needs Improve
  • Hazard A
  • Hazard B
  • Hazard C
  • Online
  • N/A

• Comments

• Call WSI @ 1-877-222-3112 to report Hazard A, B or C
  Document work order#, date and ETA below:

• WSI Contacted at:

  Date

• Work Order #

• Service Due Date

  Date

• Please document any additional items requiring inspection below:

• 1.

• 2.

• 3.

• 4.

• 5.

• 6.

• 7.

• 8.

• 9.

• 10.

• Electronic Signature

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