Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Location

Chemicals/Flammables

  • Are there any flammable cabinets at this location?

  • Is the cabinet door self-closing?

  • Are there only flammable liquids stored within the cabinets (no other liquids, tools, boxes, or PPE)?

  • Are flammable liquids in approved containers?

  • Are all containers closed?

  • Are there less than 60 gallons of flammable liquids in the cabinet?

  • Are chemicals stored within a containment?

  • Are there signs of current or past leakage within or around the containment?

  • Are containers closed when not in use?

  • Is there a spill response kit in the area?

  • Does the spill kit contain PPE?

  • Does the spill kit contain an adequate amount of absorbents to contain a spill?

  • Are employees using chemicals at this location?

  • Is proper PPE being worn when using chemicals?

  • Are chemicals being left open and unattended?

  • Are employees aware of flammable liquid storage requirements?

  • Do employees know when to clean a spill themselves and when to report?

  • Do employees know where to find a spill response kit?

  • Do employees know how to obtain an SDS for the material?

Ergonomics

  • Do employees perform high repetition tasks (100 reps/hr or 2000 reps/day)?

  • Do the employee's routine tasks require repeated heavy lifting (>20 lbs) or occasional heavy lifting (>50 lbs)?

  • Are they using proper lifting form and lifting safely?

  • Are employees using awkwardly designed tools which cause them to operate the tool outside of a neutral position for an extended period of time?

  • Do employees perform tasks with an awkward head or neck position for an extended period of time?

  • Do employees perform tasks that require awkward back angles to be held for an extended period of time?

  • Do employees perform tasks with an awkward elbow angle for an extended period of time or with extreme force application?

  • Do employees perform tasks with an awkward wrist flexion angle for an extended period of time or with extreme force application?

  • Do employees perform tasks with an awkward back/hip flexion angle for an extended period of time or with extreme force application?

  • Do employees perform tasks with an extreme reaching distance for an extended period of time or with extreme force application?

Employee Questions

  • Do you experience pain or soreness at the end of your shift?

  • Where?

  • If your job is causing you physical discomfort, who do you report it to? (Supervisor, Lead, or EHS are acceptable answers)

Machine Safety/Dress for Safety

  • Are emergency stop buttons visible, distinguishable, and within reach of the operator(s)?

  • Do the emergency stop buttons function correctly? (ask operator to demonstate)

  • Are moving parts of the machine adequately guarded in order to prevent injury?

  • Do safeguards insure that no objects will fall into the moving parts?

  • Are interlocks functional? (ask operator to demonstrate)

  • Are guards and interlocks firmly secured and not easily removable?

  • Is there evidence that safeguards have been tampered with or removed?

  • Is a conveyor present?

  • Are in-running nip points labeled?

  • Is the guard at the in-running nip point adequately spaced to minimize the chances of injury?

  • Are operators working a safe distance away from the in-running nip point(s)?

  • Are employees wearing their hair above their shoulders?

  • Are employees wearing loose clothing or jewelry that could get caught in the machine?

  • Are employees wearing firm shoes with slip resistant soles that cover the entire foot?

  • Do employees have long fingernails (more than 1/4" past the fingertip?

Employee Questions

  • Can the employee(s) demonstrate knowledge of the E-Stop locations on their machine?

  • Does the employee understand the purpose of the E-Stop as well as the components it stops and doesn't stop?

  • Is the employee aware of the locations and functions of guards and interlocks?

  • Is the employee aware of the locations of in-running nip points and the hazards they pose?

  • Is the employee aware of the PLI dress for safety requirements?

Mobile Equipment/Pedestrian Safety

  • Are manual pallet jacks used in the area?

  • Are manual pallet jacks stored safely when not in use?

  • Are operators communicating with people both visually and verbally when using a pallet jack within 5 feet of them?

  • Are the loads they are carrying safe and stable?

  • Have all hazards been removed in the area of operation?

  • Are powered pallet jacks being used in the area?

  • Has the operator filled out an inspection form?

  • Can the operator demonstrate the inspection process?

  • Does the operator have their PLI mobile equipment permit on their person?

  • Is the operator sounding their horn in congested areas and blind corners to alert pedestrians?

  • Is the operator positioned to the front and side of the powered pallet jack while it is in operation?

  • Is the operator using the powered pallet jack in an area that is too congested for safe operation?

  • Is the operator communicating both visually and verbally with people within 5 feet of them?

  • Is the load they are carrying safe and stable?

  • Are there any forklifts in use in the area?

  • Is the forklift parked safely (turned off, in neutral, forks on ground, brake engaged)?

  • Has the operator filled out an inspection form?

  • Can the operator demonstrate the inspection process?

  • Does the operator have their PLI mobile equipment permit on their person?

  • Is the operator sounding their horn in congested areas and blind corners to alert pedestrians?

  • Is the operator carrying their load close to the ground and in a manner to avoid an obstructed view?

  • Is the load safe and stable?

  • Is the operator communicating both visually and verbally with people within 5 feet of them?

  • Are pedestrians on alert, communicating both visually and verbally with operators within 5 feet of them?

  • Are pedestrians aware of the five foot rule?

PPE/Knife Use

  • Are there PPE requirements for operators in the area?

  • Are employees properly wearing the PPE required for this area?

  • If chemicals or compressed air are being used, are safety glasses being worn?

  • Are safety glasses un-tinted, with sideshields, and in good condition?

  • Are safety glasses being worn over prescription glasses when applicable?

  • If gloves are required, are employees wearing the correct gloves to address the hazard(s)?

  • Are knives used in this area?

  • Are employees only using knives issued by PLI?

  • Can the blade be left exposed when not in use?

  • If metal-bladed knives are unguarded not automatically retracting, is a cut glove being used on the non-cutting hand?

  • Would a safer knife be feasible for this task?

  • Are employees using proper cutting techniques?

Employee Questions

  • Are employees aware of the PPE requirements for their area?

  • Do employees know when and how to get PPE?

  • If employees use knives, do they know proper cutting techniques?

Housekeeping/Slip, Trip, and Fall

  • Are floors clean and clear of waste?

  • Are floors in good condition?

  • Are personal items such as clothing and lunch boxes in assigned lockers or storage areas?

  • Is the work area clear of hazards?

  • Are aisles unobstructed and clearly and appropriately marked?

  • Are aisles and walkways wide enough to accommodate workers and equipment?

  • Is there an accumulation of waste in the work area?

  • Are waste containers adequate in size and proximity to the areas where waste is produced?

  • Are there any chemicals or rags in general waste containers?

  • Is the waste emptied regularly?

  • Is there clear access to fire extinguishers, first aid kits, and/or eyewash stations?

  • Is there a 36" clearance in front of electrical panels?

  • Are clearance zones in front of emergency equipment and electrical panels clearly marked?

Employee Questions

  • Is the employee aware of the clearance zones for electrical and emergency equipment?

  • Is the employee aware of what red/white and black/yellow tape signify?

  • Is the employee aware of locations for disposal of chemicals and rags?

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.