Information
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Document No.
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Client / Site
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Conducted on
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Prepared by
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Location
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Introduction and exchange cards
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Who is present name and title?
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Thank you for inviting MOSH consultation and your commitment to protecting your workers.
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Survey occurs in the parts
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Opening conference
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Walkthrough
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Closing conference
Opening Conference
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Any enforcement activity?
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Cost: Free service-90% federal 10% state
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Agree to terms of service?
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Modifying the scope or terminating a visit
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Full service
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Limited
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Confidentiality and trade secrets
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Relationship to enforcement and informing enforcement
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Types of hazards
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Imminent danger: Employee injury or death is likely to occur immediately or within a short period of time
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Must be corrected immediately or remove employees until corrected
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Serious: Employee injury or death may occur in time
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Must be corrected and report back including supporting documentation
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Other than serious: Employee injury possible to occur in time
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Must be corrected, but do not have to report back
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Recommendations may be made
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Employee interviews
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Photographs
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MOSH Training
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SHARP Program
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Nature of business:
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Description of workplace:
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Size of facility:
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Type of building:
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Buildings age or how long at location:
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Total number of employees:
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How many employees are present today:
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Hours of operation:
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Lunch and break times:
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Union:
Paperwork and Programs
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OSHA 300 and 300A for the past three years
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Comments:
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(If between Feb 1st and Apr 30th, is the 300A posted:)
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Injury and illness data analyzed:
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Comments:
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What is the most common injury:
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Specific safety manager:
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Comments:
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Employee involvement:
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Comments:
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Safety committee:
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Comments:
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Safety committee should:
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Evaluate the accident and illness prevention program
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Establish procedures for inspection
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Inspect the workplace for safety and health hazard
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Recommend how to eliminate hazards and unsafe behaviors
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Safety rules:
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Are safety rules separate from human resources rules:
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New employee safety training:
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How:
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Who:
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How long:
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Ongoing safety training:
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When:
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How:
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Who:
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Hazard assessment done:
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Comments:
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Hazard assessment certified:
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Comments:
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Self inspections done:
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Comments:
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Hazard training (how to recognize and correct)
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Comments:
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System for reporting hazards:
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Comments:
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System for reporting near misses:
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Comments:
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Accident investigations:
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Comments:
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Emergency action plan:
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Comments:
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Evacuation and assembly point:
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Comments:
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Someone trained in first aid/CPR:
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Comments:
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Rely on 911:
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Comments:
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System for reporting a emergency/fire:
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Comments:
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Employees are to use fire extinguishers:
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Comments:
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Fire extinguisher training:
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How:
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Who:
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When:
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Fire extinguishers visually inspected monthly:
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Who:
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Documented:
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Comments:
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Fire extinguishers annually inspected:
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PPE used:
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Type:
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How obtained:
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Training:
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When:
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How:
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Who:
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Written LOTO program:
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Comments:
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LOTO devices provided:
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Comments:
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LOTO training:
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When:
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How:
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Who:
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Tap to enter information
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LOTO periodic inspection:
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When:
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How:
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Who:
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LOTO periodic inspection certified:
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Comments:
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Written Hazard Communication Program:
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Comments:
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MSDS:
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Comments:
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Chemical information list:
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Comments:
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CIL proper format:
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CIL submitted to MDE:
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How often:
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Electrical safety-related work practices:
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Comments:
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PIT program:
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Comments:
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When:
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How:
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Who:
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Fall protection:
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Comments
Closing Conference
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Tap to enter information
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Abatement date:
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Review hazards.
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Set abatement date.
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A written report will be sent.
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It is up to the employer whether or not they want to share the report with enforcement.
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Do not wait for the report to begin hazard correction.
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List of hazards must be posted for the days or until the last serious hazard is abated. Abatement must be posted in a conspicuous area for employees to review.
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Appendix B is used to report back along with spring documentation.
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Requests for extensions must be in writing and state what the employer is doing to correct the hazard, along with what interim protection is in place.
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Training and follow-up visits can be conducted.
