Information
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Facility/Location
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Department & Manager Names
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Survey Name
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Conducted on
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Participating Personnel
Workplace Environment
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1. Employee work areas are adequately illuminated.
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Indicate corrective action needed and by what date.
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2. Employees are NOT engaged in unsafe ergonomic activities (e.g., awkward postures, prolonged repetitive motion, contact stress, bad desk setup, etc.).
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Indicate corrective action needed and by what date.
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3. Employee work areas are clean, orderly, and do not present a hazard(s).
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Indicate corrective action needed and by what date.
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4. Employees are NOT engaged in unsafe acts (e.g., using stairs as step stools or ladders, using multiple extension cords together, etc.)
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Indicate corrective action needed and by what date.
Walking & Working Surfaces
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5. Aisles are clearly established and kept clear.
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Indicate corrective action needed and by what date.
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6. No tripping hazards are present.
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Indicate corrective action needed and by what date.
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7. Floors are dry - not slippery.
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Indicate corrective action needed and by what date.
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8. Cords are not stretched across aisles, walkways, or under carpeting.
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Indicate corrective action needed and by what date.
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9. Proper entrance mats are available and used in wet weather.
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Indicate corrective action needed and by what date.
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10. Carpeting is secure and free of tears, lumps, or loose pieces that could cause a trip/fall.
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Indicate corrective action needed and by what date.
Stairways, Aisles, Storage Rooms, Halls, Emergency Exits, Fire Extinguishers
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11. There is adequate lighting in stairways, aisles, and storage rooms.
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Indicate corrective action needed and by what date.
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12. Stairways are clear - not cluttered, no storage of materials.
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Indicate corrective action needed and by what date.
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13. Stair treads are in good condition, not slippery.
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Indicate corrective action needed and by what date.
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14. Handrails are installed and in good condition - not loose.
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Indicate corrective action needed and by what date.
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15. Hallways are kept clear of equipment and supplies.
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Indicate corrective action needed and by what date.
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16. Emergency Exits doors are clearly marked and accessible.
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Indicate corrective action needed and by what date.
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17. Fire extinguishers are accessible, fully charged, properly mounted, and location identified.
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Indicate corrective action needed and by what date.
Bookcases, Shelves, Cabinets
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18. Bookcases and shelves are NOT overloaded.
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Indicate corrective action needed and by what date.
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19. Heavy storage shelves are secured to the wall to prevent tipping over.
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Indicate corrective action needed and by what date.
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20. File drawers are kept closed when not in use.
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Indicate corrective action needed and by what date.
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21. Bookcases and cabinets are secured against tipping over.
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Indicate corrective action needed and by what date.
Electrical Safety, Chairs, Chemicals, Step stools, Ladders, Air Movement
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22. Electrical outlets are not overloaded, no unauthorized adapters in use.
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Indicate corrective action needed and by what date.
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23. Equipment plugs are properly grounded (i.e., have 3 prongs if not double-insulated).
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Indicate corrective action needed and by what date.
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24. Electrical cords are properly grounded - plugs in good condition.
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Indicate corrective action needed and by what date.
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25. Extension cords are NOT used as a substitute for permanent wiring.
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Indicate corrective action needed and by what date.
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26. Chairs are in good mechanical condition - no tears, breaks, broken parts, etc.
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Indicate corrective action needed and by what date.
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27. Chemicals are properly labeled, stored, and used to minimize exposure.
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Indicate corrective action needed and by what date.
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28. Paper cutters and blade-spring functioning properly, blade is kept in the down position when not used.
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Indicate corrective action needed and by what date.
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29. Safe step stools, ladders, carts, etc., are available and used when appropriate.
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Indicate corrective action needed and by what date.
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30. No unauthorized space heaters in use.
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Indicate corrective action needed and by what date.
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31. Heating & Air Conditioning ventilation systems are unobstructed.
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Indicate corrective action needed and by what date.
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Signature of Lead Inspector
