Title Page
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Client / Site
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Location
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Conducted on
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Prepared by
General Safety
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Are chairs and other furniture in good condition?
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Are all compressed gas cylinders that may be in your area secured from falling over?
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During the survey, were all staff observed using proper body mechanics?
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In areas where items are stored or placed overhead, is there ready access to a suitable step stool, stepladder, or similar device?
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In storage areas, are the heavier items stored at waist level, with the lightest objects placed on the higher shelves?
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Are all vehicles (carts, wheelchairs, etc.) in good operating condition?
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Has personal protection equipment (as required by MSDS or other standards) been provided to all employees needing it?
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Is the area free of clutter?
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Is excess paper and combustible material improperly stored creating a fire risk?
Fire & Disaster
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Are all fire alarm pull stations and fire extinguishers accessible?
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Does all staff know the locations of fire alarm pull stations?
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Does all staff know the locations of extinguishers in or near their work area?
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All portable fire extinguishers are regularly serviced?
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Fire hoses/ Reels are sealed, operable and not used for daily operations?
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Does staff in the area know the proper reporting procedure if they find (or believe there may be) a fire?
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Is all stock kept stacked in such a way that it is not to close to light fixtures and pallets stack at a maximum of 2 pallets?
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Are all containers liquids (chemicals) labeled as to contents?
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Are all areas in compliance with “No Smoking” policies?
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when heaters are used, are they approved and do not pose a safety hazard?
Hallways, Stairs, & Exit Paths
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Are the corridors kept clear of obstructions?
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Are all wet floors marked with "CAUTION, WET FLOOR" (or similar) signs?
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Is carpeting secure to the floor, unfrayed, free from tripping hazards, and generally in good condition?
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Are hard floor surfaces secure and free of tripping and slipping hazards?
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Are floor surfaces uneven or in need of repair?
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Are all EXIT signs illuminated?
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When opened and then released, do all fire doors close and latch properly?
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Are stairwell handrails in good condition?
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Are stair treads in good condition?
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Are stairwells completely clear of obstructions and any objects?
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Is the housekeeping in this area adequate?
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Is access to electrical panels clear and not obstructed?
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Are all electrical switches & circuit breakers identified? If not, list the locations of those that are not on the back of this sheet.
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Are all electrical receptacles and cover plates in good condition?
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Are electrical cords and plugs in good condition?
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Check for damaged insulation, cut cords, splices, and tape wrapped around the cord - none of which should be present.
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Are only fused power strip extension cords, surge protectors, used (all 3 pins on the plug)?
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Does all electrical equipment in the area appear to be in good condition?
Electrical Safety
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Is access to electrical panels clear and not obstructed?
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Are all electrical switches & circuit breakers identified? If not, list the locations of those that are not on the back of this sheet.
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Are all electrical receptacles and cover plates in good condition?
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Are electrical cords and plugs in good condition? Check for damaged insulation, cut cords, splices, and tape wrapped around the cord - none of which should be present.
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Are only fused power strip extension cords, surge protectors, used (all 3 pins on the plug)?
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Does all electrical equipment in the area appear to be in good condition?
First Aid
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Are cabinets and contents clean, orderly and properly stocked?
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Are first aid kits accessible and the first aid officers identified?
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Do staff know the location of the first aid kits?
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Emergency drills held every 6 months?
Forklifts
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Daily inspections available and signed off by Management?
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Charging area clean and in good condition?
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Charging unit adequate ventilation?
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Charging unit connection in good repair?
Completion
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Recommendations
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Full Name and Signature of the Inspector