Title Page
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Zone
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- 2
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- 4
- 5
- 6
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Area
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Date
Shift
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First
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Second
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Third
page 1 - Item
Item
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Floor Condition
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Drain Covers
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Trip Hazards
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Housekeeping
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Raised Platform
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Hand/Mid/Toe Rails
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Ergo Stands
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Approval Footwear
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Icing
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Dust
Page 2 - Electrical
Electrical
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Panel Clearance
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NFPA 70E/Labeling
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Exposed Panel Blanks
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Controls Labeled
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Breaker Marked & Legible
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Temporary Wiring
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Extension Cords
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Ground plug/Double Insulated
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Conduit Condition
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GFCI
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Panels Closed
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Panels Dry
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Adequate Lighting
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Grounding
Page 3 - Tools/Equipment
Tools/Equipment
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Adequate Machine Guarding
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Safety Shutoffs
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Ladders
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Hand Tools
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Power Tools and Cords
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Cylinders Stored Properly
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Grinders Complaint
Page 4 - Chemical
Chemical
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Proper Labeling
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Proper PPE/Training
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Proper Container
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Tanks Properly Marked
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Flammable Storage
Page 5 - PPE
PPE
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Eye Protection
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Head Protection
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Foot Protection
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Check 5 Boot Treads
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Gloves (Whizard/Chain)
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Faceshield/Grinding
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Hearing Protection
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Respirators
Page 6 - PIE
PIE
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Pallet Jacks
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Battery Room
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Forklifts
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Lifts
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Jockey Trucks
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Tractors/Lawn Mowers
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Battery Room (hoist/chargers)
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Wheel Chocks
Page 7 - Emergency
Emergency
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Eyewash/Shower
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Fire Extinguisher Inspected
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Fire Extinguisher Accessible
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Exits Market
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Exits Clear
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Emergency Lighting
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Combustibles (Egress)
Page 8 - Ammonia
Ammonia
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Valve Tagging
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NH3 Smells
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Piping Conditions
Page 9 - Other
Other
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Cage Dumping Alarm/Light
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Tote Dumper Chains
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Wrapping Machine Chains
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Ice House Alarm
Miscellaneous/Comments
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Any Additional Comments?
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Optional Photo 1:
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Optional Photo 2:
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Optional Photo 3:
Signature Page
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Full Name and Signature:
