Health & Safety Audit Check List Updated 2014

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Physical Security

• Visitor Book Updated

  Yes

  No

  N/A

• Vehicle Book Updated

  Yes

  No

  N/A

• Key Register Maintained

  Yes

  No

  N/A

• Does the First Aid box checked & no expired Medicine

  Yes

  No

  N/A

Environment

• No damages on floor

  Yes

  No

  N/A

• No Cracks on Walls

  Yes

  No

  N/A

• No slippery floor

  Yes

  No

  N/A

• No Roof sealing and roof structure damage

  Yes

  No

  N/A

Fire Safety

• Fire Extinguishers tag Updated

  Yes

  No

  N/A

• Fire Main Panel Working Properly

  Yes

  No

  N/A

• Fire Main Panel Daily Check list Updated

  Yes

  No

  N/A

• Emergency Phone no's Display at the Guard Room

  Yes

  No

  N/A

Electrical Safety

• No damage in lights fitting

  Yes

  No

  N/A

• Panel board having danger Signs

  Yes

  No

  N/A

• Electrical wiring was safe and maintained at the Guard Room

  Yes

  No

  N/A

• Are all electrical panels, switch boards kept closed & rubber mats underneath

  Yes

  No

  N/A

• Are all wires insulated properly and do not obstruct any work station & no exposed wiring

  Yes

  No

  N/A

• Protective device (MCCB/MCB/Fuse) not by-passed.

  Yes

  No

  N/A

• Distribution panels/boards, breakers, TOBs, feeding units of BBT, BBT-end, junction boxes etc. are not completely enclosed and protected from dust & vermin.

  Yes

  No

  N/A

• All the electrical circuits ( Drawing ) displayed in the Panel Board

  Yes

  No

  N/A

• Phase separators shall be placed between the live conductors at MCCB terminals.

  Yes

  No

  N/A

• Are check list maintained for Electrical Panels

  Yes

  No

  N/A

• Other Observation

• On site representative

  Sign

• Auditor's signature

  Sign

Environment

• No damages on floor

  Yes

  No

  N/A

• No Cracks on Walls

  Yes

  No

  N/A

• No slippery floor

  Yes

  No

  N/A

• No Roof sealing and roof structure damage

  Yes

  No

  N/A

• Do not workers throw goods from top racks to the floor

  Yes

  No

  N/A

• Fabric Stored on the rack properly

  Yes

  No

  N/A

• Does the section is clean and tidy

  Yes

  No

  N/A

• Cleaning Check List Updated

Personnel Safety & Equipment

• Safety Boots have been worn workers

  Yes

  No

  N/A

• Safety Belt have been worn by Helper

  Yes

  No

  N/A

• Safety Helmets are worn by the stores workers

  Yes

  No

  N/A

• There are not Unsafe or damaged harness or equipment?

  Yes

  No

  N/A

• Do workers use the ladder to climb on racks

  Yes

  No

  N/A

• Does the First Aid box checked & no expired Medicine

  Yes

  No

  N/A

Machinery Equipment & Tools

• Sharp tools Controlled

  Yes

  No

  N/A

• Fork Lift maintenance Check list Updated

  Yes

  No

  N/A

Fire Safety

• Arrow marks & Pathways Clearly Marked ?

  Yes

  No

  N/A

• Pathways are not blocked

  Yes

  No

  N/A

• Fire Points are not blocked

  Yes

  No

  N/A

• Fire call points are clearly displayed & not to be obstructed

  Yes

  No

  N/A

• Fork lift are not charging in side the factory

  Yes

  No

  N/A

• Does store rooms have two exits.

  Yes

  No

  N/A

• Flammable liquids stored correctly

  Yes

  No

  N/A

• Evacuation Plan Displayed

  Yes

  No

  N/A

• Fire Hose reel not Obstructed

  Yes

  No

  N/A

• Emergency exit signs visible for all area

  Yes

  No

  N/A

• Fire Hose reel & fire pump check list updated & not obstructed

  Yes

  No

  N/A

Electrical Safety

• No damage in lights fitting

  Yes

  No

  N/A

• Panel board having danger Signs

  Yes

  No

  N/A

• Electrical wiring was safe and maintained at the Stores Section

  Yes

  No

  N/A

• Are all electrical panels, switch boards kept closed & rubber mats underneath

  Yes

  No

  N/A

• Are all wires insulated properly and do not obstruct any work station & no exposed wiring

  Yes

  No

  N/A

• Protective device (MCCB/MCB/Fuse) not by-passed.

  Yes

  No

  N/A

• Distribution panels/boards, breakers, TOBs, feeding units of BBT, BBT-end, junction boxes etc. are not completely enclosed and protected from dust & vermin.

  Yes

  No

  N/A

• All the electrical circuits ( Drawing ) displayed in the Panel Board

  Yes

  No

  N/A

• Phase separators shall be placed between the live conductors at MCCB terminals.

  Yes

  No

  N/A

• Are check list maintained for Electrical Panels

  Yes

  No

  N/A

• Other Observation

• On site representative

  Sign

• Auditor's signature

  Sign

Environment

• No damages on floor

  Yes

  No

  N/A

• No Cracks on Walls

  Yes

  No

  N/A

• No slippery floor

  Yes

  No

  N/A

• No Roof sealing and roof structure damage

  Yes

  No

  N/A

• Goods properly stack on rack/pallets

  Yes

  No

  N/A

• Does the section is clean and tidy

  Yes

  No

  N/A

• Cleaning Check List Updated

Personnel Safety & Equipment

• Employees use dust marks

  Yes

  No

  N/A

• Is the cutting area free from snap blades?

  Yes

  No

  N/A

• All the Female Employees using scarf

  Yes

  No

  N/A

• Are the employees using the metal gloves when using cutting machine

  Yes

  No

  N/A

• Binding Cutter Machines Blade Guard available & Operator aware the Safety Instructions

  Yes

  No

  N/A

• End Cuter Blade Guard Available & Operator aware the Safety Instructions

  Yes

  No

  N/A

• Straight Knife Blade Guard Available & Operator aware the Safety Instruction

  Yes

  No

  N/A

• All tools attached to work stations

  Yes

  No

  N/A

• Does the First Aid box checked & no expired Medicine

  Yes

  No

  N/A

Machinery Equipment & Tools

• All the Machines Service and calibrated

  Yes

  No

  N/A

• Daily Fusing machine check list updated

  Yes

  No

  N/A

• Daily Spreader machine check list updated

  Yes

  No

  N/A

• Availability of Manual cutter service record.

  Yes

  No

  N/A

• Daily Gerber cutter machine check list updated

  Yes

  No

  N/A

• Cutting Tables in good condition

  Yes

  No

  N/A

• Sharp tools Controlled

  Yes

  No

  N/A

Fire Safety

• Pathways are not blocked

  Yes

  No

  N/A

• Arrow marks & Pathways Clearly Marked ?

  Yes

  No

  N/A

• Fire Points are not blocked

  Yes

  No

  N/A

• Fire call points are clearly displayed & not to be obstructed

  Yes

  No

  N/A

• Fork lift are not charging in side the factory

  Yes

  No

  N/A

• Does Cutting rooms have two exits.

  Yes

  No

  N/A

• Evacuation Plan Displayed

  Yes

  No

  N/A

• Fire Hose reel not Obstructed

  Yes

  No

  N/A

• Emergency exit signs visible for all area

  Yes

  No

  N/A

• Fire Hose reel & fire pump check list updated & not obstructed

  Yes

  No

  N/A

Electrical Safety

• No damage in lights fitting

  Yes

  No

  N/A

• Panel board having danger Signs

  Yes

  No

  N/A

• Electrical wiring was safe and maintained at the Cutting Section

  Yes

  No

  N/A

• Are all electrical panels, switch boards kept closed & rubber mats underneath

  Yes

  No

  N/A

• Are all wires insulated properly and do not obstruct any work station & no exposed wiring

  Yes

  No

  N/A

• Protective device (MCCB/MCB/Fuse) not by-passed.

  Yes

  No

  N/A

• Distribution panels/boards, breakers, TOBs, feeding units of BBT, BBT-end, junction boxes etc. are not completely enclosed and protected from dust & vermin.

  Yes

  No

  N/A

• All the electrical circuits ( Drawing ) displayed in the Panel Board

  Yes

  No

  N/A

• All the electrical circuits ( Drawing ) displayed in the Panel Board

  Yes

  No

  N/A

• Are check list maintained for Electrical Panels

  Yes

  No

  N/A

• Other Observation

• On site representative

  Sign

• Auditor's signature

  Sign

Environment

• No damages on floor

  Yes

  No

  N/A

• No Cracks on Walls

  Yes

  No

  N/A

• No slippery floor

  Yes

  No

  N/A

• No Roof sealing and roof structure damage

  Yes

  No

  N/A

• Does the section is clean and tidy

  Yes

  No

  N/A

• Cleaning Check List Updated

Personnel Safety & Equipment

• All Employees wearing ear plugs

  Yes

  No

  N/A

• Wearing Mask & Scarf

  Yes

  No

  N/A

• Is the embroidery machine area free from loose and broken needles?

  Yes

  No

  N/A

• Does the First Aid box checked & no expired Medicine

  Yes

  No

  N/A

Machinery Equipment & Tools

• All the Machines Service

  Yes

  No

  N/A

• Sharp tools Controlled

  Yes

  No

  N/A

Fire Safety

• Pathways are not blocked

  Yes

  No

  N/A

• Arrow marks & Pathways Clearly Marked ?

  Yes

  No

  N/A

• Fire Points are not blocked

  Yes

  No

  N/A

• Fire call points are clearly displayed & not to be obstructed

  Yes

  No

  N/A

• Does Embroidery Section have two exits.

  Yes

  No

  N/A

• Evacuation Plan Displayed

  Yes

  No

  N/A

• Fire Hose reel not Obstructed

  Yes

  No

  N/A

• Emergency exit signs visible for all area

  Yes

  No

  N/A

• Fire Hose reel & fire pump check list updated & not obstructed

  Yes

  No

  N/A

Electrical Safety

• No damage in lights fitting

  Yes

  No

  N/A

• Panel board having danger Signs

  Yes

  No

  N/A

• Electrical wiring was safe and maintained at the Embroidery Section

  Yes

  No

  N/A

• Are all electrical panels, switch boards kept closed & rubber mats underneath

  Yes

  No

  N/A

• Are all wires insulated properly and do not obstruct any work station & no exposed wiring

  Yes

  No

  N/A

• Protective device (MCCB/MCB/Fuse) not by-passed.

  Yes

  No

  N/A

• Distribution panels/boards, breakers, TOBs, feeding units of BBT, BBT-end, junction boxes etc. are not completely enclosed and protected from dust & vermin.

  Yes

  No

  N/A

• All the electrical circuits ( Drawing ) displayed in the Panel Board

  Yes

  No

  N/A

• Phase separators shall be placed between the live conductors at MCCB terminals.

  Yes

  No

  N/A

• Are check list maintained for Electrical Panels

  Yes

  No

  N/A

• Other Observation

• On site representative

  Sign

• Auditor's signature

  Sign

Environment

• No damages on floor

  Yes

  No

  N/A

• No Cracks on Walls

  Yes

  No

  N/A

• No slippery floor

  Yes

  No

  N/A

• No Roof sealing and roof structure damage

  Yes

  No

  N/A

• Does the section is clean and tidy

  Yes

  No

  N/A

• Cleaning Check List Updated

Personnel Safety & Equipment

• Does the First Aid box checked & no expired Medicine

  Yes

  No

  N/A

• All Employees use Scarf & dust marks

  Yes

  No

  N/A

• All tools attached to work stations

  Yes

  No

  N/A

• All Iron-ers use rubber mat & wear slippers when Ironing

  Yes

  No

  N/A

Machinery Equipment & Tools

• Sharp tools Controlled

  Yes

  No

  N/A

• Do All machines have all guards ?

  Yes

  No

  N/A

• Eye Guards

• Needle Guards

• Pully Guards

• Moter Guards

• Belt Guard

• Safety Guard

• Do all machines have machine maintenance card?

  Yes

  No

  N/A

• Are all snap attaching machines fitted with safety guard Check random Operation

  Yes

  No

  N/A

Fire Safety

• Pathways are not blocked

  Yes

  No

  N/A

• Arrow marks & Pathways Clearly Marked ?

  Yes

  No

  N/A

• Fire Points are not blocked

  Yes

  No

  N/A

• Fire call points are clearly displayed & not to be obstructed

  Yes

  No

  N/A

• Evacuation Plan Displayed

  Yes

  No

  N/A

• Fire Hose reel not Obstructed

  Yes

  No

  N/A

• Emergency exit signs visible for all area

  Yes

  No

  N/A

• Fire Hose reel & fire pump check list updated & not obstructed

  Yes

  No

  N/A

Electrical Safety

• No damage in lights fitting

  Yes

  No

  N/A

• Panel board having danger Signs

  Yes

  No

  N/A

• Electrical wiring was safe and maintained at the Production

  Yes

  No

  N/A

• Are all electrical panels, switch boards kept closed & rubber mats underneath

  Yes

  No

  N/A

• Are all wires insulated properly and do not obstruct any work station & no exposed wiring

  Yes

  No

  N/A

• Protective device (MCCB/MCB/Fuse) not by-passed.

  Yes

  No

  N/A

• Distribution panels/boards, breakers, TOBs, feeding units of BBT, BBT-end, junction boxes etc. are not completely enclosed and protected from dust & vermin.

  Yes

  No

  N/A

• All the electrical circuits ( Drawing ) displayed in the Panel Board

  Yes

  No

  N/A

• Phase separators shall be placed between the live conductors at MCCB terminals.

  Yes

  No

  N/A

• Are check list maintained for Electrical Panels

  Yes

  No

  N/A

• Other Observation

• On site representative

  Sign

• Auditor's signature

  Sign

Environment

• No damages on floor

  Yes

  No

  N/A

• No Cracks on Walls

  Yes

  No

  N/A

• No slippery floor

  Yes

  No

  N/A

• No Roof sealing and roof structure damage

  Yes

  No

  N/A

• Does the section is clean and tidy

  Yes

  No

  N/A

• Cleaning Check List Updated

Personnel Safety & Equipment

• Does the First Aid box checked & no expired Medicine

  Yes

  No

  N/A

• All Employees use Scarf & dust marks

  Yes

  No

  N/A

• All tools attached to work stations

  Yes

  No

  N/A

Machinery Equipment & Tools

• Sharp tools Controlled

  Yes

  No

  N/A

• Do All machines have all guards ?

  Yes

  No

  N/A

• Moter Guards

• Belt Guard

• Safety Guard

• Needle Guards

• Pully Guards

• Eye Guards

• Do all machines have machine maintenance card?

  Yes

  No

  N/A

• Are all snap attaching machines fitted with safety guard Check random Operation.

  Yes

  No

  N/A

Fire Safety

• Pathways are not blocked

  Yes

  No

  N/A

• Arrow marks & Pathways Clearly Marked ?

  Yes

  No

  N/A

• Fire Points are not blocked

  Yes

  No

  N/A

• Fire call points are clearly displayed & not to be obstructed

  Yes

  No

  N/A

• Evacation Plan Displayed

  Yes

  No

  N/A

• Emergency exit signs visible for all area

  Yes

  No

  N/A

• Fire Hose reel & fire pump check list updated & not obstructed

  Yes

  No

  N/A

Electrical Safety

• Auditor's signature

  Sign

• No damage in lights fitting

  Yes

  No

  N/A

• Panel board having danger Signs

  Yes

  No

  N/A

• Electrical wiring was safe and maintained at the TPD Section

  Yes

  No

  N/A

• Are all electrical panels, switch boards kept closed & rubber mats underneath

  Yes

  No

  N/A

• Are all wires insulated properly and do not obstruct any work station & no exposed wiring

  Yes

  No

  N/A

• Protective device (MCCB/MCB/Fuse) not by-passed.

  Yes

  No

  N/A

• Distribution panels/boards, breakers, TOBs, feeding units of BBT, BBT-end, junction boxes etc. are not completely enclosed and protected from dust & vermin.

  Yes

  No

  N/A

• All the electrical circuits ( Drawing ) displayed in the Panel Board

  Yes

  No

  N/A

• Phase separators shall be placed between the live conductors at MCCB terminals.

  Yes

  No

  N/A

• Are all wires insulated properly and do not obstruct any work station

  Yes

  No

  N/A

• Are check list maintained for Electrical Panels

  Yes

  No

  N/A

• Other Observation

• On site representative

  Sign

Environment

• No damages on floor

  Yes

  No

  N/A

• No Cracks on Walls

  Yes

  No

  N/A

• No slippery floor

  Yes

  No

  N/A

• No Roof sealing and roof structure damage

  Yes

  No

  N/A

• Does the section is clean and tidy

  Yes

  No

  N/A

• Cleaning Check List Updated

Personnel Safety & Equipment

• Does the First Aid box checked & no expired Medicine

  Yes

  No

  N/A

• All Employees use Scarf & dust marks

  Yes

  No

  N/A

• All tools attached to work stations

  Yes

  No

  N/A

Machinery Equipment & Tools

• Sharp tools Controlled

  Yes

  No

  N/A

• Do All machines have all guards ?

  Yes

  No

  N/A

• Safety Guard

• Eye Guards

• Needle Guards

• Pully Guards

• Moter Guards

• Belt Guard

• Do all machines have machine maintenance card ?

  Yes

  No

  N/A

• Are all snap attaching machines fitted with safety guard Check random Operation.

  Yes

  No

  N/A

Fire Safety

• Pathways are not blocked

  Yes

  No

  N/A

• Arrow marks & Pathways Clearly Marked ?

  Yes

  No

  N/A

• Fire Points are not blocked

  Yes

  No

  N/A

• Fire call points are clearly displayed & not to be obstructed

  Yes

  No

  N/A

• Evacation Plan Displayed

  Yes

  No

  N/A

• Emergency exit signs visible for all area

  Yes

  No

  N/A

• Fire Hose reel & fire pump check list updated & not obstructed

  Yes

  No

  N/A

Electrical Safety

• No damage in lights fitting

  Yes

  No

  N/A

• Panel board having danger Signs

  Yes

  No

  N/A

• Electrical wiring was safe and maintained at the Training Section

  Yes

  No

  N/A

• Are all electrical panels, switch boards kept closed & rubber mats underneath

  Yes

  No

  N/A

• Are all wires insulated properly and do not obstruct any work station & no exposed wiring

  Yes

  No

  N/A

• Protective device (MCCB/MCB/Fuse) not by-passed.

  Yes

  No

  N/A

• Distribution panels/boards, breakers, TOBs, feeding units of BBT, BBT-end, junction boxes etc. are not completely enclosed and protected from dust & vermin.

  Yes

  No

  N/A

• All the electrical circuits ( Drawing ) displayed in the Panel Board

  Yes

  No

  N/A

• Phase separators shall be placed between the live conductors at MCCB terminals.

  Yes

  No

  N/A

• Are check list maintained for Electrical Panels

  Yes

  No

  N/A

• Other Observation

• On site representative

  Sign

• Auditor's signature

  Sign

Environment

• No damages on floor

  Yes

  No

  N/A

• No Cracks on Walls

  Yes

  No

  N/A

• No slippery floor

  Yes

  No

  N/A

• No Roof sealing and roof structure damage

  Yes

  No

  N/A

• Do not workers throw goods from top racks to the floor

  Yes

  No

  N/A

• Finished Goods Stored k properly

  Yes

  No

  N/A

• Does the section is clean and tidy <br>

  Yes

  No

  N/A

• Cleaning Check List Updated

Personnel Safety & Equipment

• Visitor access (in /out) documented

  Yes

  No

  N/A

• Safety Boots have been worn workers

  Yes

  No

  N/A

• Safety Belt have been worn by Helper

  Yes

  No

  N/A

• Safety Helmets are won by the FGS workers

  Yes

  No

  N/A

• Do workers use the ladder to climb on racks

  Yes

  No

  N/A

• Does the First Aid box checked & no expired Medicine

  Yes

  No

  N/A

Machinery Equipment & Tools

• Sharp tools Controlled

  Yes

  No

  N/A

• Fork Lift maintenance Check list Updated

  Yes

  No

  N/A

Fire Safety

• Pathways are not blocked

  Yes

  No

  N/A

• Arrow marks & Pathways Clearly Marked ?

  Yes

  No

  N/A

• Fire Points are not blocked

  Yes

  No

  N/A

• Fire call points are clearly displayed & not to be obstructed

  Yes

  No

  N/A

• Fork lift are not charging in side the factory

  Yes

  No

  N/A

• Does FGS rooms have two exits.

  Yes

  No

  N/A

• Evacation Plan Displayed

  Yes

  No

  N/A

• Fire Hose reel & fire pump check list updated & not obstructed

  Yes

  No

  N/A

Electrical Safety

• On site representative

  Sign

• Auditor's signature

  Sign

• No damage in lights fitting

  Yes

  No

  N/A

• Panel board having danger Signs

  Yes

  No

  N/A

• Emergency exit signs visible for all area

  Yes

  No

  N/A

• Electrical wiring was safe and maintained at the FGS Section<br>

  Yes

  No

  N/A

• Are all electrical panels, switch boards kept closed & rubber mats underneath<br>

  Yes

  No

  N/A

• Are all wires insulated properly and do not obstruct any work station<br>

  Yes

  No

  N/A

• Are check list maintained for Electrical Panels<br>

  Yes

  No

  N/A

• Other Observation

Environment

• No damages on floor

  Yes

  No

  N/A

• No Cracks on Walls

  Yes

  No

  N/A

• No slippery floor

  Yes

  No

  N/A

• No Roof sealing and roof structure damage

  Yes

  No

  N/A

• Does the section is clean and tidy ?

  Yes

  No

  N/A

• Cleaning Check List Updated

Fire Safety

• Pathways are not blocked

  Yes

  No

  N/A

• Arrow marks & Pathways Clearly Marked ?

  Yes

  No

  N/A

• Fire Points are not blocked<br>

  Yes

  No

  N/A

• Fire call points are clearly displayed & not to be obstructed<br>

  Yes

  No

  N/A

• Does Office rooms have two exits.<br>

  Yes

  No

  N/A

• Evacation Plan Displayed <br>

  Yes

  No

  N/A

• Emergency exit signs visible for all area

  Yes

  No

  N/A

• Fire Hose reel & fire pump check list updated & not obstructed

  Yes

  No

  N/A

Electrical Safety

• No damage in lights fitting

  Yes

  No

  N/A

• Panel board having danger Signs

  Yes

  No

  N/A

• Electrical wiring was safe and maintained at the Office area

  Yes

  No

  N/A

• Are all electrical panels, switch boards kept closed & rubber mats underneath<br>

  Yes

  No

  N/A

• Are all wires insulated properly and do not obstruct any work station & no exposed wiring <br>

  Yes

  No

  N/A

• Protective device (MCCB/MCB/Fuse) not by-passed.

  Yes

  No

  N/A

• Distribution panels/boards, breakers, TOBs, feeding units of BBT, BBT-end, junction boxes etc. are not completely enclosed and protected from dust & vermin.

  Yes

  No

  N/A

• All the electrical circuits ( Drawing ) displayed in the Panel Board

  Yes

  No

  N/A

• Phase separators shall be placed between the live conductors at MCCB terminals.

  Yes

  No

  N/A

• Are check list maintained for Electrical Panels<br>

  Yes

  No

  N/A

• Other Observation

• On site representative

  Sign

• Auditor's signature

  Sign

Boiler Room

Environment

• No Roof sealing and roof structure damage <br>

  Yes

  No

  N/A

• No damages on floor<br>

  Yes

  No

  N/A

• No Cracks on Walls<br>

  Yes

  No

  N/A

• No slippery floor<br>

  Yes

  No

  N/A

• Does the boiler room is clean and tidy ?<br>

  Yes

  No

  N/A

• Cleaning Check List Updated

Personnel Safety & Services

• Boilers daily Safely Vales check list available

  Yes

  No

  N/A

• Boiler Operator having Certificate<br>

  Yes

  No

  N/A

• PPE Training has been done for Operators<br>

  Yes

  No

  N/A

• Boiler service records available <br>

  Yes

  No

  N/A

Fire Safety

• Pathways are not blocked<br>

  Yes

  No

  N/A

• Arrow marks & Pathways Clearly Marked ?<br>

  Yes

  No

  N/A

• Fire Points are not blocked<br>

  Yes

  No

  N/A

• Fire call points are clearly displayed & not obstructed<br>

  Yes

  No

  N/A

Electrical Safety

• No damage in lights fitting<br>

  Yes

  No

  N/A

• Panel board having danger Signs<br>

  Yes

  No

  N/A

• Emergency exit signs visible for all area<br>

  Yes

  No

  N/A

• Electrical wiring was safe and maintained at the Boiler Room<br>

  Yes

  No

  N/A

• Are all electrical panels, switch boards kept closed & rubber mats underneath<br>

  Yes

  No

  N/A

• Are all wires insulated properly and do not obstruct any work station & no exposed wiring

  Yes

  No

  N/A

• Protective device (MCCB/MCB/Fuse) not by-passed.

  Yes

  No

  N/A

• Distribution panels/boards, breakers, TOBs, feeding units of BBT, BBT-end, junction boxes etc. are not completely enclosed and protected from dust & vermin.

  Yes

  No

  N/A

• All the electrical circuits ( Drawing ) displayed in the Panel Board

  Yes

  No

  N/A

• Phase separators shall be placed between the live conductors at MCCB terminals.

  Yes

  No

  N/A

• Are check list maintained for Electrical Panels<br>

  Yes

  No

  N/A

Compressor Room

Environment

• No damages on floor<br>

  Yes

  No

  N/A

• No Cracks on Walls<br>

  Yes

  No

  N/A

• No slippery floor<br>

  Yes

  No

  N/A

• No Roof sealing and roof structure damage <br>

  Yes

  No

  N/A

• Does the Compressor room is clean and tidy <br>

  Yes

  No

  N/A

• Cleaning Check List Updated

Personnel Safety & Services

• PPE Training has been done for Operators

  Yes

  No

  N/A

• Ear muff & Safety Equipment provided

  Yes

  No

  N/A

Fire Safety

• Pathways are not blocked<br>

  Yes

  No

  N/A

• Compressor service records available

  Yes

  No

  N/A

• Arrow marks & Pathways Clearly Marked ?<br>

  Yes

  No

  N/A

• Fire Points are not blocked<br>

  Yes

  No

  N/A

• Fire call points are clearly displayed & not to be obstructed<br>

  Yes

  No

  N/A

Electrical Safety

• No damage in lights fitting<br>

  Yes

  No

  N/A

• Panel board having danger Signs<br>

  Yes

  No

  N/A

• Emergency exit signs visible for all area<br>

  Yes

  No

  N/A

• Electrical wiring was safe and maintained at the Compressure Room<br>

  Yes

  No

  N/A

• Are all electrical panels, switch boards kept closed & rubber mats underneath<br>

  Yes

  No

  N/A

• Are all wires insulated properly and do not obstruct any work station & no exposed wiring

  Yes

  No

  N/A

• Protective device (MCCB/MCB/Fuse) not by-passed.

  Yes

  No

  N/A

• Distribution panels/boards, breakers, TOBs, feeding units of BBT, BBT-end, junction boxes etc. are not completely enclosed and protected from dust & vermin.

  Yes

  No

  N/A

• All the electrical circuits ( Drawing ) displayed in the Panel Board

  Yes

  No

  N/A

• Are check list maintained for Electrical Panels<br>

  Yes

  No

  N/A

Maintenance Work Shop

Environment

• No damages on floor<br>

  Yes

  No

  N/A

• No Cracks on Walls<br>

  Yes

  No

  N/A

• No slippery floor<br>

  Yes

  No

  N/A

• No Roof sealing and roof structure damage <br>

  Yes

  No

  N/A

• Does the Compressor room is clean and tidy <br>

  Yes

  No

  N/A

• Cleaning Check List Updated

Personnel Safety & Services

• PPE Training has been done for Operators<br>

  Yes

  No

  N/A

• Eye guards provided for all grinding machines

  Yes

  No

  N/A

Fire Safety

• Pathways are not blocked

  Yes

  No

  N/A

• Compressor service records available <br><br>

  Yes

  No

  N/A

• Arrow marks & Pathways Clearly Marked ?<br>

  Yes

  No

  N/A

• Fire Points are not blocked<br>

  Yes

  No

  N/A

• Fire call points are clearly displayed & not to be obstructed<br>

  Yes

  No

  N/A

Electrical Safety

• No damage in lights fitting<br>

  Yes

  No

  N/A

• Panel board having danger Signs<br>

  Yes

  No

  N/A

• Emergency exit signs visible for all area<br>

  Yes

  No

  N/A

• Electrical wiring was safe and maintained at the Compressor Room<br>

  Yes

  No

  N/A

• Are all electrical panels, switch boards kept closed & rubber mats underneath<br>

  Yes

  No

  N/A

• Are all wires insulated properly and do not obstruct any work station<br>

  Yes

  No

  N/A

• Are check list maintained for Electrical Panels<br>

  Yes

  No

  N/A

Generator Room

Environment

• No damages on floor<br>

  Yes

  No

  N/A

• No Cracks on Walls<br>

  Yes

  No

  N/A

• No slippery floor<br>

  Yes

  No

  N/A

• No Roof sealing and roof structure damage <br>

  Yes

  No

  N/A

• Does the Generator room is clean and tidy <br>

  Yes

  No

  N/A

• Cleaning Check List Updated

Personnel Safety & Services

• PPE Training has been done for Operators<br>

  Yes

  No

  N/A

• Ear muff & Safety Equipment provided

  Yes

  No

  N/A

• Generator service records available

  Yes

  No

  N/A

Fire Safety

• Pathways are not blocked<br>

  Yes

  No

  N/A

• Arrow marks & Pathways Clearly Marked ?<br>

  Yes

  No

  N/A

• Fire Points are not blocked<br>

  Yes

  No

  N/A

• Fire call points are clearly displayed & not to be obstructed<br>

  Yes

  No

  N/A

Electrical Safety

• No damage in lights fitting<br>

  Yes

  No

  N/A

• Panel board having danger Signs<br>

  Yes

  No

  N/A

• Emergency exit signs visible for all area<br>

  Yes

  No

  N/A

• Electrical wiring was safe and maintained at the Generator Room<br>

  Yes

  No

  N/A

• Are all electrical panels, switch boards kept closed & rubber mats underneath<br>

  Yes

  No

  N/A

• Are all wires insulated properly and do not obstruct any work station<br>

  Yes

  No

  N/A

• Are check list maintained for Electrical Panels<br>

  Yes

  No

  N/A

Chemical Room

Environment

• Are all chemicals stored neatly<br>

  Yes

  No

  N/A

• Chemical Handling and maintenance is satisfied <br>

  Yes

  No

  N/A

Fire Safety

• Are the chemicals stored kept locked when not in use.<br>

  Yes

  No

  N/A

• Do all chemicals have secondary containment.<br>

  Yes

  No

  N/A

• Are there any other waste or combustible items stored along with chemicals.<br>

  Yes

  No

  N/A

• All hazardous, flammable, or combustible material stored in approved containers in designated storage areas, or appropriate flammable liquid storage cabinets.<br>

  Yes

  No

  N/A

• No hazardous materials, flammable chemicals, or combustible materials may be stored on the roof of any facility, dormitory, or canteen.<br>

  Yes

  No

  N/A

• Hazardous materials, flammable chemicals, and combustible materials must be kept away from ignition and heat sources.<br>

  Yes

  No

  N/A

• All hazardous or flammable materials maintained outside the designated storage area should be limited to the amount necessary for use during one shift or eight hours maximum.<br>

  Yes

  No

  N/A

Personnel Safety & Equipment

• Is there MSDS posted for all chemicals<br>

  Yes

  No

  N/A

• Are all chemicals ladled properly (with sinhala)<br>

  Yes

  No

  N/A

• Safety Equipment provided for Chemical Handlers<br>

  Yes

  No

  N/A

• Are eating,drinking,smoking & sleeping prohibited sign posted.<br>

  Yes

  No

  N/A

• Are chemical storage area away from production areas.<br>

  Yes

  No

  N/A

• Are the spot cleaning workers wearing appropriate mask,goggles and gloves.<br>

  Yes

  No

  N/A

• Hazardous and flammable material may only be handled by properly trained personnel.<br>

  Yes

  No

  N/A

• Other Observation

General

• No Slippery Floor ?

  Yes

  No

  N/A

• Is it neat and clean, free of flies,cats etc…<br>

  Yes

  No

  N/A

• Are all table tops clean.<br>

  Yes

  No

  N/A

• Is there hot water provided to drink.<br>

  Yes

  No

  N/A

• Is there a fly catching system.<br>

  Yes

  No

  N/A

• Are aprons,gloves and hair nets for used by food handlers.<br>

  Yes

  No

  N/A

• Do the workers share common cup/ glass.<br>

  Yes

  No

  N/A

• Are medical tests available for food handlers.<br>

  Yes

  No

  N/A

• Are there suggestion box in canteen.<br>

  Yes

  No

  N/A

• Does the wash basins & drains clean in canteen?

  Yes

  No

  N/A

• Daily Food wastage updated

  Yes

  No

  N/A

Fire Safety

• Pathways are not blocked<br>

  Yes

  No

  N/A

• Arrow marks & Pathways Clearly Marked ?<br>

  Yes

  No

  N/A

• Fire Points are not blocked<br>

  Yes

  No

  N/A

• Fire call points are clearly displayed & not to be obstructed<br>

  Yes

  No

  N/A

• Evacation Plan Displayed <br>

  Yes

  No

  N/A

• Fire Hose reel not Obstructed<br>

  Yes

  No

  N/A

• Fire Hose reel & fire pump check list updated & not obstructed<br>

  Yes

  No

  N/A

Electrical Safety

• No damage in lights fitting<br>

  Yes

  No

  N/A

• Panel board having danger Signs<br>

  Yes

  No

  N/A

• Emergency exit signs visible for all area<br>

  Yes

  No

  N/A

• Electrical wiring was safe and maintained at the canteen<br>

  Yes

  No

  N/A

• Are all electrical panels, switch boards kept closed & rubber mats underneath<br>

  Yes

  No

  N/A

• Are all wires insulated properly and do not obstruct any work station<br>

  Yes

  No

  N/A

• Are check list maintained for Electrical Panels<br>

  Yes

  No

  N/A

• Other Observation

• Are the maternity leave benefits available to the workers.

  Yes

  No

  N/A

• Does the factory have trained and certified first aid team.<br>

  Yes

  No

  N/A

• Are there adequately stocked first aid boxes.<br>

  Yes

  No

  N/A

• Does the factory have a sick room ( at least two beds.)<br>

  Yes

  No

  N/A

• Is there a portable First Aid Box at the Medical Center<br>

  Yes

  No

  N/A

• Are there periodic visits by a doctor.<br>

  Yes

  No

  N/A

• Are there individual health records being maintained.<br>

  Yes

  No

  N/A

• Is an accident register maintained.<br>

  Yes

  No

  N/A

• Is there drinking water available close to work station.<br>

  Yes

  No

  N/A

• Does Sickness Summary Display in the notice board<br>

  Yes

  No

  N/A

• Does Monthly Accident Summary Display in the notice board<br>

  Yes

  No

  N/A

• Is the drinking water tested periodically.<br>

  Yes

  No

  N/A

Fire Safety

• Pathways are not blocked<br>

  Yes

  No

  N/A

• Arrow marks & Pathways Clearly Marked ?<br>

  Yes

  No

  N/A

• Fire Points are not blocked<br>

  Yes

  No

  N/A

• Fire call points are clearly displayed & not to be obstructed<br>

  Yes

  No

  N/A

Electrical Safety

• No damage in lights fitting<br>

  Yes

  No

  N/A

• Panel board having danger Signs<br>

  Yes

  No

  N/A

• Emergency exit signs visible for all area<br>

  Yes

  No

  N/A

• Electrical wiring was safe and maintained at the Generator Room<br>

  Yes

  No

  N/A

• Are all electrical panels, switch boards kept closed & rubber mats underneath<br>

  Yes

  No

  N/A

• Are all wires insulated properly and do not obstruct any work station<br>

  Yes

  No

  N/A

• Are check list maintained for Electrical Panels<br>

  Yes

  No

  N/A

• Other Observation

• Number of toilets as per local labor law for male /female workers<br>

  Yes

  No

  N/A

• <br>No slippery floor<br>

  Yes

  No

  N/A

• Covered bin provided<br>

  Yes

  No

  N/A

• Water available<br>

  Yes

  No

  N/A

• no water leeks

  Yes

  No

  N/A

• Is there no any open drain?<br>

  Yes

  No

  N/A

• No Damaged doors and Mirrors

  Yes

  No

  N/A

• Sanitary bins are clean & not damaged ?

  Yes

  No

  N/A

• Does the toilets are clean and tidy ?<br>

  Yes

  No

  N/A

• Cleaning Check List Updated

• Other Observation

• PPE training has been done for Employees ?

  Yes

  No

  N/A

• Stores

• EMB

• Cutting

• Training

• TPD

• Production

• FGS

• Fire Extinguisher Inspection done

  Yes

  No

  N/A

• Stores

• Cutting

• TPD

• EMB

• Training

• Production

• FGS

• Emergency & Exit Light Check List Updated

  Yes

  No

  N/A

• Stores

• Cutting

• TPD

• EMB

• Training

• Production

• FGS

• Canteen

• Office

• Generator Room,Boiler Room,Electrical Room

• Are all new workers given training in the followings.

  Yes

  No

  N/A

• Safety issues including fire drills

• use of personal protective equipment (PPE)

• Health and sanitation issues

• Are the emergency telephone No's posted.

  Yes

  No

  N/A

• Stores

• Cutting

• TPD

• EMB

• Training

• Production

• FGS

• Canteen

• Office

• Are the photographs if the safety committee displayed on the notice board

  Yes

  No

  N/A

• Hoist examined and tested by competent person (12 Months)

  Yes

  No

  N/A

• Chains examined and tested by competent person (12 Months)<br>

  Yes

  No

  N/A

• Ropes examined and tested by competent person (6 Months)<br>

  Yes

  No

  N/A

• Lifting tackles examined and tested by competent person (6 Months) <br>

  Yes

  No

  N/A

• Steam Boiler examined and tested by an Authorized Officer (12 Months<br>

  Yes

  No

  N/A

• Steam receiver examined and tested by an Authorized Officer (24 Months)<br>

  Yes

  No

  N/A

• Air receiver examined and tested by an Authorized Officer (24 Months)<br>

  Yes

  No

  N/A

• Gas receiver examined and tested by an Authorized Officer (24 Months)<br>

  Yes

  No

  N/A

Health and Safety

• Does Health and safety standards apply to all facilities, including factories, dormitories, and canteens ?<br>

  Yes

  No

  N/A

• Doe the facility adopt procedures to limit dangers to workers from these hazards ?<br>

  Yes

  No

  N/A

• Does the facility has designated a safety management representative at each facility ? (This representative shall be responsible for worker health and safety in the facility.)<br>

  Yes

  No

  N/A

• Does the Facility implement procedures and safeguards to prevent accidents and injuries to workers ?

  Yes

  No

  N/A

• Does the facility have structure maintenance, and proper fire prevention. ? ( Procedures and safeguards should include but not be limited to proper equipment maintenance, established inspection routines, adequate worker training and protection )

  Yes

  No

  N/A

• Aren't there unreasonable or uncontrolled risks to worker health and safety ?

  Yes

  No

  N/A

• Does health and safety training provide for all new or reassigned workers and management ?

  Yes

  No

  N/A

• Does training records create and maintain for all workers ?

  Yes

  No

  N/A

• Does it cover required reasonably health and safety training hazards workers encounter in the scope of their work ?

  Yes

  No

  N/A

Permits and Building Design

• Does facility maintain a valid fire license or permit as required by applicable law. If required by law, is it display in a visible location ?

  Yes

  No

  N/A

• Does the Facility have obtained valid construction approvals as required by applicable law ? ( If the local law does not provide for such approvals, a certification by a Wallmart-approved third-party civil or structural engineer that the facility is structurally sound must be obtained.)

  Yes

  No

  N/A

• Does the building design and construction standards are applicable at the facility comply with local law and any ?<br>

  Yes

  No

  N/A

• Does the facility have obtained and maintained valid zoning permits as required by applicable law ?<br>

  Yes

  No

  N/A

Emergency Exits and Evacuation

• Does Aisles, exits, and stairwells kept clear and unblocked at all times ?<br>

  Yes

  No

  N/A

• Does evacuation plan included an evacuation route map that is accurate as to the facility, posted in the local language, and includes a “you are here” mark.?<br>

  Yes

  No

  N/A

• Does the facility posted Enough evacuation maps in work stations and main aisles inside the facility to allow workers to easily and quickly find emergency exits ?<br>

  Yes

  No

  N/A

• Does the facility have marked and lighted emergency exit routes with visible and operable emergency lights for all occupied floors and areas of the building, including stairwells ?<br>

  Yes

  No

  N/A

• Does emergency lights fire grade “industrial emergency lights” for use in smoke and fire environments & facilities have a secondary power source connected to these lights for use in the event of electricity power failure ?<br>

  Yes

  No

  N/A

• Doe the facility have at least the minimum number of emergency exits per occupied floor or any portion there of as calculated based on the occupancy rate table below.? ( Only facilities with areas smaller than 750 square feet (70 square meters) and occupancy of less than 10 persons are permitted to have one emergency exit )<br>

  Yes

  No

  N/A

• Are there 2 or more exits for 10 - 499 persons ?<br>

  Yes

  No

  N/A

• Are there 3 or more exits for 500 – 1000 persons ?<br>

  Yes

  No

  N/A

• Are there 4 or more exits for >1000 persons ?<br>

  Yes

  No

  N/A

• Does all emergency exits must be properly marked with illuminated “Exit” signs in the local language?<br>

  Yes

  No

  N/A

• Does External fire escape routes are preferred ? ( For this requirement, only the exceptions allowed under the National Fire Protection Association 101 Life Safety Code (NFPA 101) will be considered.)<br>

  Yes

  No

  N/A

• Does Multi-story facilities have a sufficient number of appropriately protected escape routes.?<br>

  Yes

  No

  N/A

• Does the Escape routes include one-hour fire-rated enclosed staircases if the fire escape services more than one floor, or external fire escape routes.?<br>

  Yes

  No

  N/A

• Does emergency exits separated by a reasonable distance from other emergency exits?<br>

  Yes

  No

  N/A

• Does emergency exits located on opposite ends of buildings are preferred, and at a minimum located on more than one wall ?<br>

  Yes

  No

  N/A

• Does multiple emergency exits cannot share same emergency travel route ?<br>

  Yes

  No

  N/A

• Does all emergency exit doors must be maintained in an unlocked, accessible, and usable condition ?<br>

  Yes

  No

  N/A

• Does emergency exit doors open readily from the occupied side and swing in the direction of emergency travel.<br>

  Yes

  No

  N/A

• Can emergency exit doors operate with a push bar or single motion operation requiring minimal effort or force ? (for interior doors no more than 5 lbf (22 N), for exterior doors no more than 50 lbf (222 N)) to open.<br>

  Yes

  No

  N/A

• Does it require special keys or knowledge to open Doors?<br>

  Yes

  No

  N/A

• Does windows designated as emergency exits ? (if permitted by law, but shall not be included as an emergency exit for the purposes of these Standards.)<br>

  Yes

  No

  N/A

• Does the facility have an internal emergency release mechanism. If a window has designated as an emergency exit ?<br>

  Yes

  No

  N/A

• "Does travel distance to an exit from any point in the building comply with the following maximum distances, as measured along the path of travel. ? ( Where these limitations cannot be met, additional exits or rearrangement of egress configuration should be considered.)<br>Non-Sprinklered - 200ft / 61m<br>Sprinklered - 250ft / 76m"<br>

  Yes

  No

  N/A

• Does evacuation routes lead to safe assembly points located outside the facility ?<br>

  Yes

  No

  N/A

• Does the Assembly points have designated as assembly points ? ( be located a safe distance from the facility, and be kept clear at all times.)<br>

  Yes

  No

  N/A

• Does the facility have automatic closure system for doors to emergency exit stairwells and fire escapes that can be released manually from the inside ?<br>

  Yes

  No

  N/A

Emergency Responder Access to Facility

• Does the Facility allow to access fire response and emergency response vehicles to the facility premises ?<br>

  Yes

  No

  N/A

• Can Emergency vehicles must be able to reach the facility by road or a cleared path ?<br>

  Yes

  No

  N/A

• Does emergency responders must have free and unobstructed access to water sources, the fire sprinkler system, and gas cutoffs ?<br>

  Yes

  No

  N/A

Fire Safety Equipment

• Are there fire extinguishing equipment that is adequate for the hazard level of the facility operations ?<br>

  Yes

  No

  N/A

• Does all fire extinguishing equipment must be functional, accessible, and properly maintained ?<br>

  Yes

  No

  N/A

• Does all fire extinguishing equipment inspected at least once per month and these inspections documented ?<br>

  Yes

  No

  N/A

• Does all the Fire extinguishing equipment kept clear and accessible at all times ?<br>

  Yes

  No

  N/A

• Does the facility have at least a single alarm system throughout all areas and floors of the building ?<br>

  Yes

  No

  N/A

• Does the Fire alarm systems provide adequate notice to evacuate, including audible alarms and flashing lights ? ( High noise areas (90 dB or higher) should also include an alarm that has a beacon/flashing light designed to draw attention in the high noise area. )<br>

  Yes

  No

  N/A

• Does the facility have a secondary power supply connected to the fire alarm system in case of electrical power failure ?<br>

  Yes

  No

  N/A

Country Specific Requirements

• Does the facility follow local legal requirements regarding sprinkler and fire hydrant systems ?<br>

  Yes

  No

  N/A

• Does Sprinkler and fire hydrant systems inspected quarterly by internal staff and annually by independent fire inspection companies. ? (The date of inspection, inspector, and results of the inspection should be recorded by the Supplier.)<br>

  Yes

  No

  N/A

• Does the facility ensure that adequate water supply is available for sprinkler and fire hydrant systems in the event of a fire emergency ?<br>

  Yes

  No

  N/A

• Does the facility have water storage tank or cistern is used as an emergency water supply for fire-fighting purposes ? ( it should be verified that it is of sufficient capacity as required by law and is kept filled.)<br>

  Yes

  No

  N/A

Fire Safety Committee

• Does the facilities have a fire safety committee, or assign this responsibility to an existing committee.<br>

  Yes

  No

  N/A

• Does the facility safety committees made up of workers, management, and representatives from high hazard areas to discuss and address fire safety concerns and improve fire safety practices ?<br>

  Yes

  No

  N/A

• Are all fire safety committee meetings ( EHS ) documented ?<br>

  Yes

  No

  N/A

Fire Safety Inspections

• Does the facility buildings inspected not less than once a month by trained personnel to ensure that all fire safety standards are met ? ( If any fire safety standards are not met, facilities and buildings are to be inspected on a daily basis until the facility meets all fire safety standards.)<br>

  Yes

  No

  N/A

• Does Inspection date, time, and results documented ?<br>

  Yes

  No

  N/A

Fire Safety Training

• Does the facility conducted evacuation drills a minimum of once every year ? (If there are sprinkler or hydrant systems )<br>

  Yes

  No

  N/A

• Does the facility conducted evacuation drills a minimum of once every 3 months ? ( If there are not sprinkler or hydrant systems)<br>

  Yes

  No

  N/A

• Does the facility conducted evacuation drills a minimum of once every 3 months ?( If there are not sprinkler or hydrant systems)<br>

  Yes

  No

  N/A

• Does the facility maintain documentation of evacuation drills ? which should include the drill date, number of participants, and the amount of time taken to effectively evacuate the facility.<br>

  Yes

  No

  N/A

• Does the facility have multiple businesses within a single building? ( If Yes ,ensure all workers have proper joint evacuation training )<br>

  Yes

  No

  N/A

• Does the facility provided training on the facility’s emergency action plan to all workers ? (Training must occur no less than once every 6 months )<br>

  Yes

  No

  N/A

• Does the facility ensure the initial hiring and training process includes emergency action plan training ?<br>

  Yes

  No

  N/A

• Does all emergency action plan training documented ?<br>

  Yes

  No

  N/A

• Does the facility have designated emergency response personnel identified, trained, and present for each floor, building, and shift.?<br>

  Yes

  No

  N/A

• will emergency response personnel be in charge of evacuating the building in the event of a fire emergency.<br>

  Yes

  No

  N/A

• Does designated emergency response personnel trained to notify workers of a fire or emergency, report fires and other emergencies to the fire department or designated emergency response organization, assist in the evacuation of workers, and verify that all workers have exited the building ?<br>

  Yes

  No

  N/A

• Does designated emergency response personnel easily identifiable by all workers in the event of an emergency ? (e.g. specific arm band, flag, or uniform) and there should be two emergency response persons designated per shift.<br>

  Yes

  No

  N/A

• Does the facility designated emergency response personnel fulfilled by fire brigades where they are required by law and meet these standards.?<br>

  Yes

  No

  N/A

Electrical Safety

• Does the facility have a documented electrical system maintenance program ?<br>

  Yes

  No

  N/A

• Does the facility have electrical maintenance program including routine inspections of the electrical system of the building for damaged wiring, separated conduits, improper installations, and overloaded or damaged circuits ?<br>

  Yes

  No

  N/A

• Does the Inspection records kept, including the date of inspection, the inspector, and the results of the inspection ?<br>

  Yes

  No

  N/A

• Does the facility ensure that extension cords are not being utilized for permanent application and that multiple outlet adapters or “surge protector strips” are not being connected to one other ?<br>

  Yes

  No

  N/A

• Does the facility implement an annual infrared scan program for all of electrical systems, including panel boards, wiring and other equipment, to detect potential ignition sources ?<br>

  Yes

  No

  N/A

• Other Observation

• Summary Report by Auditor

• Name of Auditor

• Auditor Signature

  Sign

• Comments by Head of Department

• Name of Head of Department

• Department Head Signature

  Sign