Information

  • Company Name

  • Conducted on

  • Prepared by

  • Location

Parking Lot

Conditions

  • Painted crosswalk?

  • Painted curbs?

  • Crosswalk contains stop signs?

  • Minimal debris in parking lot? (glass, trash, ect.)

  • Other?

Behaviors

  • Employees wearing high visibility vests?

  • Employees push max of 5 carts at a time?

  • No horseplay/employees not "riding on carts"?

  • Other?

Department Grade

  • Overall Grade

  • Produce manager or shift supervisor signature.

Produce Department

Conditions

  • Floor mats under grapes and cherries?

  • Floor mats under all sources of water spray? Veg sprayers, asparagus, flowers.

  • Floor mats in good condition?

  • Floor is free from debris?

  • Produce bag stand is stable on floor/overhead?

  • Other?

Behaviors

  • Employees wearing slip resistant shoes?<br>

  • Employee using hand cart to stock merchandise?

  • Boxes on hand carts do not exceed height of shoulders on employee.

  • Employees demonstrating good behaviors (not horsing around)?

  • Employees observed picking up debris off floor?

  • Hazard cones on display only when hazards exist at that time?

  • Other?

Department Grade

  • Overall Grade

  • Produce manager or shift supervisor signature.

Deli Department

Conditions

  • Floor mats on floor?

  • Floor mats in good condition?

  • Floor is free from debris?

  • Slicer contains proper guarding?

  • Slicer contains proper hand piece?

  • Slicer cords contain ground plug?

  • Slicer cords contain no exposed wiring?

  • Knife storage available by magnets or holders?

  • Other?

Behaviors

  • Employees wearing slip resistant shoes?<br>

  • Employees using a cut resistant glove any time a knife is being used?

  • Employees wearing cut resistant gloves when cleaning slicer?

  • Employees using slicer properly?

  • Employees "0" out slicer hand dial.

  • Knives are put away when not in use, not laying around on tables?

  • Other?

Department Grade

  • Overall Grade

  • Produce manager or shift supervisor signature.

Meat Department

Conditions

  • Floor mats on floor?

  • Floor mats in good condition?

  • Floor is free from excess debris/blood?

  • Meat grinder contains guard?

  • Band saw contains guard?

  • Other?

Behaviors

  • Employees wearing slip resistant shoes?<br>

  • Employees wearing cut resistant gloves?

  • Employees NOT wearing gloves when using band saw?

  • Guard on band saw adjusted above meat when in use?

  • Guard on band saw completely down when not in use?

  • Employees not using milk crates to stand on?

  • Floors are free from cardboard?

  • Other?

Department Grade

  • Overall Grade

  • Produce manager or shift supervisor signature.

Bakery Department

Conditions

  • Floor mats on floor?

  • Floor mats in good condition?

  • Floor is free from debris?

  • Mixers contain guards?

  • Other?

Behaviors

  • Employees wearing slip resistant shoes?<br>

  • Employees wearing cut resistant gloves?

  • Employees use guards on mixers?

  • Other?

Department Grade

  • Overall Grade

  • Produce manager or shift supervisor signature.

Back of House / Housekeeping

Conditions

  • Step stools/ladders available in each walk-in coolers?

  • Step stools/ladders are clean with minimal food debris in steps?

  • Squeegee available in eachs coolers?

  • Wheels on carts in good condition.

  • Coolers free from excess water?

  • Freezers free from ice?

  • Milk crates stored no more than 6 high?

  • Aisles clear from trip hazards?

  • Ample lighting and visibility?

  • Floor mats under sinks and ice makers?

  • 15 minute flow eye wash station near forklift charging station?

  • Other?

Behaviors

  • Employees practice proper lifting techniques?

  • Employees wearing seatbelt on forklifts.

  • Employees engage parking brake when not in use.

  • Employees lower forks to the floor when not in use.

  • Employees observed driving slowly on forklifts?

  • Employees not standing on storage racks without fall protection?

  • Fire exits free from obstructions?

  • Electrical panels free from obstructions?

  • Extension cords are:<br>- Used for temporary basis<br>- Are contained into one room, not extending into multiple areas<br>- In good condition - no frayed wiring<br>- Not daisy chained (linking multiple extension cords/power strips)

  • Floors are free from cardboard?

  • No overhead storage on top of walk-ins, mezzanines, ect?

  • All fire extinguishers are mounted to a wall and not placed on floor?

  • Fire extinguishers contain current year on tag (2014/2013) with monthly signatures on back of tag?

  • Other?

Store Manager Acknowledgement

Overall Store Grade

  • Overall Grade

  • Store Manager Signature

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.