Title Page
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Account Name
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Client Name
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Conducted on
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Prepared by
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Address of Site
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BU#
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Start-up Date
Personnel and Scope
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Division
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VP of Operations
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Regional Manager
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Area Manager
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Account Manager
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Supervisor
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Regional Safety Director
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Regional HR Director
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Scope of Work
- Janitorial
- Facilities Operations and Maintenance
- Grounds Maintenance
- Transportation/Rental Car Services
- Production
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Attach a copy of the Contract ' s Scope of Work to this Assessment
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Specific Tasks within Scope of Work
- Offices
- Classrooms and hallways
- Kitchens/Kitchenettes
- Restrooms
- Conference Rooms
- Computer/Server Rooms
- Boiler/Mechanical Rooms
- Clean Rooms
- Entrances
- Transportation/Car Rental Services
- Packaging
- Warehousing/Material Handling
- Tree/shrub trimming
- Lawn maintenance
- Seasonal clean-up
- Sweeping/grounds maintenance
- Trash pick up/removal
- Graffiti removal
Equipment
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Existing Facilities Available
- Storage closet (s)
- First Aid /Occupational Health Services
- Employee Restrooms
- Employee lockers
- GCA office space
- WiFi/Internet Access
- Employee parking
- Badging system
- On-site security personnel
- Dedicated land line telephone
- Automated Electronic Defibrillator (AED)
- Employee cafeteria
- Refrigerator
- Kitchen facilities
- Red bag/Biological disposal
- Sharps disposal
- Other
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Comments or additional information
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Equipment Needed
- First Aid Kit
- Eye wash
- Lock-out Tag-out kit
- Employee lockers
- Flammables storage cabinet
- Chemical labels
- Key box
- Spill clean-up kit
- Electrical extension cords
- Ground fault circuit interrupters (GFCI)
- Retractible utility knives
- Other
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Comments of additional information
Risks Based On Tasks
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Physical Hazards
- Forklift operation
- Working with Balers
- Working with Compactors
- Loading or Unloading trailers
- Bending
- Lifting more than 30 lbs
- Reaching
- Twisting/Pulling/Pushing
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Does the Scope include facility cleaning?
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Select hazards introduced by facility cleaning tasks
- Slips/Trips (same level)
- Slips/Trips (stairs)
- Falls (to lover level)
- Electrical (extension cords, vacuums, powered equipment)
- Sharp objects
- Ladders/step stools
- Office drawers, file cabinets
- Working behind blind doors
- Bending
- Lifting
- Reaching
- Twisting/Pushing/Pulling
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Does the Scope include landscaping services?
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Select hazards introduced by landscaping services
- Mowers
- String trimmers
- Fire hazards
- Pesticide/herbicide exposures
- Weather hazards
- Dehydration
- Insects
- Poisonous plants
- Animals/pests
- Gasoline/diesel/oils exposures
- Bending
- Lifting more than 30 lbs.
- Reaching
- Twisting/Pushing/Pulling
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Does the Scope include Transportation/Rental Car Services?
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Transportation/Rental Car Services Hazards
- Vehicle washing
- Vehicle fueling
- Vehicle fluids top off
- Shuttling on lot
- Shuttling off lot
- Customer Van/Shuttle service
- Regional/Local market vehicle distribution
- Baggage valet
- Gate attendant
- Urban/suburban driving
- Rural driving
- International driving (Canada, Mexico)
- Bending/kneeling
- Lifting more then 30 lbs.
- Reaching
- Twisting/Pushing/Pulling
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Does the Scope include warehouse services?
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Warehouse hazards
- Forklift operation
- Working with Balers
- Working with Compactors
- Loading or Unloading trailers
- Bending
- Lifting more than 30 lbs
- Reaching
- Twisting/Pulling/Pushing
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Additional hazards not listed.
