Information
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Conducted on
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Prepared by
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Client Name:
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Address:
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Contact/Title
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Description of Business:
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Who's responsible for safety at the facility/Contact information:
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# of permanent employees
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# of Field Associates Anticipated
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Workers' Comp. Code
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Standard Industry Code (SIC)
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Summary of client's OSHA Log for the current year and one prior year:
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Year Total # of Incidents Recorded - Add Total Days Away From Work - Total Days Restricted Work Activity - columns G, H, I & J of OHSA Form 300 column K of OSHA Form 300 column L of OSHA Form 300
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Year Total # of Incidents Recorded - Add Total Days Away From Work - Total Days Restricted Work Activity - columns G, H, I & J of OHSA Form 300 column K of OSHA Form 300 column L of OSHA Form 300
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Most frequent injury: In what department(s):
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Most severe injury: In what department(s):
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Are Field Associates included on the OSHA Log?
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Does the client have a safety program and will our Field Associates be included in the safety activities?
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Is the facility clean and organized with defined aisles, marked pathways and smooth, level flooring?
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Is personal protective equipment (PPE) required?
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If so, please list the type(s) of PPE required:
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Who will provide the PPE to our Field Associates?
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Does the client have and enforce policies on speed limit, right of way, use of seatbelts, traveling with loads, etc. while operating a PIT?
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Do the PITs appear to be in good repair?
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What types of PITs will our employees operate?
- Stand-up
- Reach
- Sit-down
- Order Picker
- Electric Pallet Jack
- Other
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Is the client capable of managing non-English speaking employees, if applicable?
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Will the Field Associates be on ladders over 4 feet?
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Explain what they will be doing:
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Do the positions require heavy lifting? (>20 lbs.)?
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If so, what is the maximum the Field Associates will need to be able to lift?
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Does the client have an adequate PIT Operator Training Program?
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Who will complete the Visual Evaluation of our PIT Operators?
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Do any of the positions require our employees to drive a motor vehicle?
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Did someone from our office tour the facility before the first placement? Who?
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Date of Evaluation:
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Date of First Placement:
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ProLogistix policy states that Field Associates are not allowed to lift more than 50 lbs. unassisted (contact your Corporate Safety Consultant if lifting over 50 lbs. is required), nor are they allowed to drive a motor vehicle for client business. After careful observation and analysis, I recommend this as a safe and healthful environment for our Field Associates.
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Staff Member Signature
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Submitted by: Branch #: Phone#: Customer ID#:
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Send to: risk.services@employbridge.net with New Client in the subject line or fax (214) 614-4612. Include job descriptions if available.
