Information
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Department / Area / Machine #
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Document No.
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Conducted on
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Prepared by
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Location
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Personnel
Departmental Inspections & Meetings
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Safety meeting or safety talk performed by Supervisor or Lead
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Housekeeping / safety inspection completed for previous month?
Housekeeping
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Housekeeping Pics
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Cleanliness of floor?
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Area free of trash?
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Are there misc. items / parts / personal items placed in nooks, cranny's, cubby holes that looks like CLUTTER?
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Racks and shelves organized?
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Racks and shelves are properly labeled?
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Walkways and passages clear to walk?
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Brooms, mops, etc... Stored correctly when not in use?
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Desks, tables, toolbox & counters clean?
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Any excessive dust noticed? (Special enfaces on combustible dust)
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Are cords and hoses out of aisles and walkways?
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Empty pallets, crates, or boxes removed from area before they become "clutter"?
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Area around trash cans, bins, dumpsters, scrap bins is clean?
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Drains, sinks or drinking fountains clean and free of spills?
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Pics of "Clutter" or poor Housekeeping.
(PPE) Personal Protective Equipment
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PPE Pics
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Employees wearing safety glasses at all times?
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Employees wearing gloves when exposed to cuts, scrapes, burns or chemical hazards?
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Arm/wrist protectors worn as required?
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Employees wearing face shield during grinding, sanding or other operations when required?
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Face shield or splash goggles worn during chemical operations? (Splash Hazard into eyes)
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Hearing Protection worn properly by employees when required?
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Condition of PPE? (Clean & sanitary condition)
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PPE properly stored when not being used?
Electrical
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Electrical Pics
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Breaker box cover / door is closed when not in use?
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Electrical panels, Breaker boxes, Disconnect boxes unobstructed? ( 3 ft clearance)
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Electrical panels and devices labeled and secured?
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Are GFCI outlets being used properly or needed in this area?
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Cover plates or switch plates in place?
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Extension cords in good condition?
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Extension cords NOT used on a permanent basis?
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Extension cords not used across aisle ways or walk ways.
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A quick (random) inspection was performed.
Machinery & Machine Guarding
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Machine Pics
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Is the current guard(s) effective?
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Is the Light curtain working properly?
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Do adjustable arms for light curtains have padlocks in place?
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Potential for employee to reach (Over, Under, Around, Through) the guard?
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E-stop properly labeled (Emergency Shut-off)?
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Pinch Points labeled?
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Caution / Warning signs in place?
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Are all gates, grates, fencing, pin guards, etc in place to prevent employee from entering a hazardous area or nip point.
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Are moving parts guarded (belts, shafts, rotating/reciprocating parts, pinch points, etc.)?
Hand and Power Tools
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Tool Pics
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Power Tools free from damage (switches and guards)?
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Cords free from damage or frays?
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Cord plug is equipped with ground plug....electrical?
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Hand tools free from damage ( handles, shaft, head, etc.)?
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Safety guards in place? (Grinders, sanders, etc.)
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Grinders have handles in place and free from damage?
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A quick (random) inspection was performed.
( Crane/Hoist ) - Lifting Devices / Lifting Components
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Properly stored when not in use?
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Properly tagged or labeled?
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Is tag / label legible?
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A quick (random) inspection was performed.
Emergency / First Aid
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Clear access to fire extinguishers?
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Clear assess to fire hose?
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Are fire extinguishers properly mounted?
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Are fire extinguisher signs in place or pole painted "RED"?
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Fire extinguisher inspections current?
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Access to Emergency fire exits?
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Access to First Aid items / kit?
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Emergency Pics
Eye Wash Station
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Eye Wash Pics
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Accessible or clear path?
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Are adequate signs marking the location?
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Clean (Free from dust, dirt or other debris)?
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Expiration date ok or last inspection ok?
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Continuous flow unit has adequate flow or water pressure?
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Caps or covers in place when not in use?
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A quick (random) inspection was performed.
Fall Protection
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Elevated work levels (Over 4 feet high) have guardrails or railing at the proper height of 42" with mid-rail at approx 21"?
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Are fall arrest (Harness, Lanyard, Clips, Hooks) inspected?
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Last documented inspection date.
Chemicals
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Chemical Pics
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All chemical containers labeled?
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Chemical spill kits available near by?
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Chemicals used and/or stored in an approved containers?
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Aerosol cans have lids/caps in place when not in use?
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Flammable materials stored properly in flammable proof cabinet? (Ie:Acetone, Paint, etc.)
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Flammable drums properly grounded / bonded to prevent sparks during transferring process?
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Waste or spent chemicals properly disposed of?
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Adequate number of fire extinguishers in place?
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Space heaters properly located away from flammables?
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Are there items that have the potential to catch fire or possibility to cause a fire.
Welding
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Are welding screens safely in place around welding work areas?
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Are welding screens clean or free from excessive dust?
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Are welding gas bottles secured to rack, cart or fixture to prevent it from falling?
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Are caps in place on bottles not being used?
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Hoses and/or cords free from defects?
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PAPR or Supplied air welding hood needed?
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A quick (random) inspection was performed.
Ladders (Fixed or Portable)
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Stored or secured correctly while not in use?
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Ladders free from defects or damage?
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Properly labeled or identified?
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A quick (random) inspection was performed.
Slip,Trip Hazards / Walking & Working Surfaces
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Slip, Trip Hazard Pics
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Spills or leaks?
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Cords or hoses across aisle ways or walk ways?
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Misc. items obstructing aisle ways?
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Any holes in floor have been reported to Supervisor or Maintenance to be fixed?
Environmental
Waste & Waste Reduction (Hazardous, Non-Haz, Universal)
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Drums have lids and/or caps in place when not in use?
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Waste drums properly labeled?
Pollution Prevention
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BMP's include: Good Housekeeping, Preventive Maintenance, SOP's, Spill Prevention, Training, Inspections
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Are BMP's (Best Management Practices) observed to prevent pollution?
Recycling
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Are good recycling practices taking place?
Water Conservation
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Any leaks or drips noticed?
Energy Conservation
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Are lights turned off when applicable? (ie: natural light is plentiful or motion sensors are used)
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Excess machinery, electrical devices are unplugged breakers turned off when not being utilized?
Waste water
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Any observations of unauthorized items being disposed of down the drain?
Storm Water
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Storm water drain access is clear and free from debris?
Secondary Containment
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Is secondary containment being used?
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Free from cracks, holes, etc?
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Describe the type of secondary containment.
Unsafe acts observed?
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Unsafe Acts?
For this area/dept, How many accidents have occurred since the last assessment?
Are there Risk controls that have failed or need to be enhanced in order to prevent future injuries?
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PPE (Besides Safety Glasses & Steel Toes)
- Full Suit
- Gloves
- Boots
- Hood
- Faceshield
- Welding Gear
- Respirator, PAPR, SAR
- Hearing Protection
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Engineering Controls
- Guard Rails
- Preventive Maintenance
- Gated Access
- Machine Guards
- Cranes
- Forklift / Powered Industrial Truck
- E-Stop, pumps, sensors, monitors
- Secondary Containment
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Administrative Controls / Work Practice Controls
- Work Instructions
- SOP's
- Training
- Safety Meeting
- Two Way Radios
- Inspections/Audits
- R2A2 (Roles, Responsibilities, Accountability, Authority
- Housekeeping
- Decontamination
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Communication Controls
- 2 Person Checklist
- Maps
- Signs / Posters
- Meetings
- Training / Awareness
- Investigations
- Other Visual communications
- Verbal Communication from Supervisor/Lead
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Additional comments on control failures.
Review
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Overall review?
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Supervisor or Lead signature
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EHS Manager signature
