Information

  • Document No.

  • Dow - Deer Park

  • Dow - La Porte

  • Dow - Bayport

  • Dow - Lonestar

  • Dow - Texas City

  • Employee

  • Supervisor

  • Manager

  • Assessor

  • Select date

Hazard Analysis

  • Task analysis used correctly

  • STAC score > 3

  • STAC complete and score

At Risk Program

  • Knowledgeable of Day's Key Learning

  • Previous Day's Key Learnings

Personal Protective Equipment

  • Correct Eye Protection

  • Correct Foot Protection

  • Correct Clothing Worn/Jewelry

  • Wearing Correct Gloves for Task

Badges

  • Badges on Person

  • Safety Council Training Current

Escape Respirator

  • Respirator on Person

  • Date on Cartridge

  • Proper Operating Condition

Process Safety

  • Location of nearest Safety Shower/Eyewash

  • Location of Phones/Intercoms

Evacuation

  • Correct Wind Direction

  • Correct Assembly Point

Work Area Hazard

  • Janitor closet condition

  • MSDS locator log

Equipment

  • Equipment inspection

  • GFCI

  • Frayed Cords/Plugs W/O ground

JEP

  • All employees signed on

  • JEP accurate to scope and location

Incident/Injury Process

  • Emergency #'s Understood

  • Reason for calling ambulance

Building Inspection

Restroom/Changerooms

  • Overall cleanliness

  • Dispenser filled?

  • Sink and fixture clean?

  • Commodes clean

  • Trash taken out?

  • Floor swept/mopped?

  • Showers

Office/Conference Room/Control Room

  • Overall cleanliness

  • Vacuum/Swept/Mopped?

  • Dusting?

Kitchen

  • Overall cleanliness

  • Floors swept/mopped?

  • Trash emptied

  • Counters/Sinks/Fixture Clean?

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.