Health and Safety Verification Form - Pace

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• Foster a safe and secure restaurant environment and protect shareholder value in order to promote the health, safety, and wellbeing of our restaurant staff, guests, and assets.
  See the US Health & Safety Guide for assessment criteria and guidance

Critical Health & Safety

• HS1-US Emergency Exits/Fire Extinguishers: Are all emergency exits and fire extinguishing equipment visible, accessible, operational and in good condition?

  Yes

  No

  N/A

• Select reasons

  Select exit door(s) is locked from inside requiring a key to open exit door(s) or path to exit(s) is blocked preventing passage exit door(s) are not properly marked as exit exit door(s) are not operational exit door(s) do not have approved panic hardware installed fire extinguisher(s) are blocked, not visible, properly mounted off the floor or readily accessible fire extinguisher(s) indicator gauge is not in the green arc fire extinguisher(s) do not have restaurant monthly inspection tags signed off or service company inspection punch-out tag walk-in refrigerators and/or freezers do not have working emergency door release other

  • exit door(s) is locked from inside requiring a key to open
  • exit door(s) or path to exit(s) is blocked preventing passage
  • exit door(s) are not properly marked as exit
  • exit door(s) are not operational
  • exit door(s) do not have approved panic hardware installed
  • fire extinguisher(s) are blocked, not visible, properly mounted off the floor or readily accessible
  • fire extinguisher(s) indicator gauge is not in the green arc
  • fire extinguisher(s) do not have restaurant monthly inspection tags signed off or service company inspection punch-out tag
  • walk-in refrigerators and/or freezers do not have working emergency door release
  • other

• Specify

• HS2-US Personal Protective Equipment (PPE): Is personal protective equipment (e.g.: face shield, apron, gloves, oven mitts) accessible and in good condition and being used correctly?

  Yes

  No

  N/A

• Select reasons

  Select personal protective equipment not readily accessible or available in restaurant holes or tears in gloves, mitts, apron, or cracks in face shield observed PPE not being used when it should, or not used correctly other

  • personal protective equipment not readily accessible or available in restaurant
  • holes or tears in gloves, mitts, apron, or cracks in face shield
  • observed PPE not being used when it should, or not used correctly
  • other

• Specify

• HS3-US Cooking Equipment Fire Suppression System: Does the restaurant have an automatic, fixed fire suppression system(s) installed over the fryer and grills? Is the system in good condition and inspected and serviced by a qualified service company at least every six months?

  Yes

  No

  N/A

• Select reasons

  Select no automatic fire suppression system (ex: Ansul) installed over all fryers and grills some automatic fire suppression system(s) installed, but not over all fryers and grills automatic fire suppression system in disrepair or non-functioning automatic fire suppression system has not been inspected/serviced within the last 6 months other

  • no automatic fire suppression system (ex: Ansul) installed over all fryers and grills
  • some automatic fire suppression system(s) installed, but not over all fryers and grills
  • automatic fire suppression system in disrepair or non-functioning
  • automatic fire suppression system has not been inspected/serviced within the last 6 months
  • other

• Specify

• HS4-US Carbon Dioxide Tanks: Are CO2 (Carbon Dioxide) tank, beverage and cylinder systems secured and in good condition?

  Yes

  No

  N/A

• Select reasons

  Select bulk CO2 tank or high pressure cylinders are dented, corroded or shows signs of excessive frosting (some frosting near the top/bottom of the tank in high use periods or immediately after refilling is acceptable) CO2 tank vent line is visibly disconnected from fill box or other connection that vents to the outdoors, spliced together or has cuts or holes in it bulk CO2 tank vent line consists of more than one piece spliced together bulk CO2 tank vent line does not have a clear traceable path lines show cracks, kinks, loose fittings, other miscellaneous signs of damage high pressure cylinders are not secured tightly (to prevent tipping) bulk CO2 tank fill box or where vent line discharges is improperly located (must be located outdoors, above ground level, and not surrounded by other walls/structures) other

  • bulk CO2 tank or high pressure cylinders are dented, corroded or shows signs of excessive frosting (some frosting near the top/bottom of the tank in high use periods or immediately after refilling is acceptable)
  • CO2 tank vent line is visibly disconnected from fill box or other connection that vents to the outdoors, spliced together or has cuts or holes in it
  • bulk CO2 tank vent line consists of more than one piece spliced together
  • bulk CO2 tank vent line does not have a clear traceable path
  • lines show cracks, kinks, loose fittings, other miscellaneous signs of damage
  • high pressure cylinders are not secured tightly (to prevent tipping)
  • bulk CO2 tank fill box or where vent line discharges is improperly located (must be located outdoors, above ground level, and not surrounded by other walls/structures)
  • other

• Specify

• HS5-US CO2 Alarm System: Are CO2 Detectors, warnings and equipment installed correctly and operational (A Carbon Monoxide - or CO detector is not acceptable)?

  Yes

  No

  N/A

• Select reasons

  Select CO2 detector(s) is not present (e.g. missing in basement, not installed in exterior closet, 2nd detector not installed in building with exterior closet, etc.) CO2 detector(s) is not installed correctly (e.g. not located by bulk tank/portable cylinders, > 12-18 inches off floor, not plugged in, has tape or bag covering detector, etc.) Non-approved CO2 detector(s) or system installed CO2 detector(s) or Central Display Unit’s indicator/power light is not operational CO2 warning signs are not present at entrances where bulk tanks, cylinder, beverage machines and bag-in-box containers are located warning strobe/siren is not audible/visible from outside the entrance to the CO2 area and/or within entire room where CO2 tank is located other

  • CO2 detector(s) is not present (e.g. missing in basement, not installed in exterior closet, 2nd detector not installed in building with exterior closet, etc.)
  • CO2 detector(s) is not installed correctly (e.g. not located by bulk tank/portable cylinders, > 12-18 inches off floor, not plugged in, has tape or bag covering detector, etc.)
  • Non-approved CO2 detector(s) or system installed
  • CO2 detector(s) or Central Display Unit’s indicator/power light is not operational
  • CO2 warning signs are not present at entrances where bulk tanks, cylinder, beverage machines and bag-in-box containers are located
  • warning strobe/siren is not audible/visible from outside the entrance to the CO2 area and/or within entire room where CO2 tank is located
  • other

• Specify

• HS6-US PlayPlace Equipment: Is the restaurant free of obsolete/unapproved equipment in use (Big Mac Climber, outdoor metal slides, electric rides, bounce and bend, riders with spring base, swings, etc.)?

  Yes

  No

  N/A

• If there is obsolete equipment, check equipment below

  Select ball pools Big Mac climbers box or cargo netting ( 2-inch square netting is not approved) on outside of play structures below 84 inches carousels (electric) electric riders and other similar moving equipment fireman poles Grimace bounce and bend loose fill safety surfacing: wood chips, bark mulch, engineered wood fibers, sand, gravel or shredded tires outdoor metal decks/slides/steps merry-go-rounds or whirls open-sided slides with platform height greater that 60 in. above surface riders with protruding handles riders with spring-type bases all swings teeter-totters/see-saws tug-n-turn unapproved vending machines and prizes non-commercial (retail purchased) and fitness center equipment inflatable play equipment (e.g. bouncy tents, castles, slides, etc.) “winged” slide runout walls on slide exits other

  • ball pools
  • Big Mac climbers
  • box or cargo netting ( 2-inch square netting is not approved) on outside of play structures below 84 inches
  • carousels (electric)
  • electric riders and other similar moving equipment
  • fireman poles
  • Grimace bounce and bend
  • loose fill safety surfacing: wood chips, bark mulch, engineered wood fibers, sand, gravel or shredded tires
  • outdoor metal decks/slides/steps
  • merry-go-rounds or whirls
  • open-sided slides with platform height greater that 60 in. above surface
  • riders with protruding handles
  • riders with spring-type bases
  • all swings
  • teeter-totters/see-saws
  • tug-n-turn
  • unapproved vending machines and prizes
  • non-commercial (retail purchased) and fitness center equipment
  • inflatable play equipment (e.g. bouncy tents, castles, slides, etc.)
  • “winged” slide runout walls on slide exits
  • other

• Specify

Occupational Safety

• HS7-US Safety Standards and Regulatory Compliance: Are managers and crew trained on and can explain the restaurant’s Emergency Action Plan (EAP) safety standards and procedures?

  Yes

  No

  N/A

• Select reasons

  Select current Emergency Action Plan (EAP) not found or in place new hire training and ongoing safety training not occurring McDonald's O&T/local regulatory safety standards not followed other

  • current Emergency Action Plan (EAP) not found or in place
  • new hire training and ongoing safety training not occurring
  • McDonald's O&T/local regulatory safety standards not followed
  • other

• Specify

Restaurant Fire Prevention and Protection

• HS8-US Are the ventilation hoods, ducts, and fans over fryers and grills inspected by a qualified service company every three months, and cleaned at a minimum of every 6 months or sooner based on inspection results? (For locations with Cascade Plus filters and Automist system: inspect quarterly and clean per inspection results).

  Yes

  No

  N/A

• Select reasons

  Select vent hoods etc. not inspected quarterly or cleaned by qualified company every six months or sooner (based on inspection results) exhaust fan is not operational while cooking equipment is turned on other

  • vent hoods etc. not inspected quarterly or cleaned by qualified company every six months or sooner (based on inspection results)
  • exhaust fan is not operational while cooking equipment is turned on
  • other

• Specify

• HS9-US Are grill and fryer filters, blank off plates, and grease collection cups cleaned regularly, installed correctly, and in good repair? Is the exhaust fan operational while cooking equipment is turned on?

  Yes

  No

  N/A

• Select reasons

  Select grill fryer filters, blank off plates, hood grease collection cups not cleaned or not installed correctly other

  • grill fryer filters, blank off plates, hood grease collection cups not cleaned or not installed correctly
  • other

• Specify

• HS10-US Are the grill and fryers free of excessive food debris and grease underneath the equipment?

  Yes

  No

  N/A

• Select reasons

  Select grill fryer filters, blank off plates, hood grease collection cups not cleaned or not installed correctly other

  • grill fryer filters, blank off plates, hood grease collection cups not cleaned or not installed correctly
  • other

• Specify

• HS11-US Are electrical outlets, connectors, and cords in good repair?

  Yes

  No

  N/A

• Select reasons

  Select electrical outlets, connectors and cords not in good repair exposed wiring found inside or outside of the restaurant outlet plate is not in place or damaged exposing wires or connectors unapproved use of extension cords other

  • electrical outlets, connectors and cords not in good repair
  • exposed wiring found inside or outside of the restaurant
  • outlet plate is not in place or damaged exposing wires or connectors
  • unapproved use of extension cords
  • other

• Specify

• HS12-US Do all managers know the location and operation of the main controls for shutting off electricity, natural/LP gas, and water leading into the building?

  Yes

  No

  N/A

• Select reasons

  Select managers do not know location of main gas line, and electrical service shutoff or how to operate gas, water, or electric shut-off valve could not be located gas, water, or electric shut-off valve was not accessible or non-functioning other

  • managers do not know location of main gas line, and electrical service shutoff or how to operate
  • gas, water, or electric shut-off valve could not be located
  • gas, water, or electric shut-off valve was not accessible or non-functioning
  • other

• Specify

• HS13-US Is the inside of the restaurant free of gasoline or other flammable liquids, unless properly stored in an approved fire cabinet?

  Yes

  No

  N/A

• Select reasons

  Select equipment containing gasoline or other flammable liquids are stored inside the restaurant (e.g. lawnmowers, edger's, or snow blowers) fire cabinet not installed for flammable liquids stored in restaurant other

  • equipment containing gasoline or other flammable liquids are stored inside the restaurant (e.g. lawnmowers, edger's, or snow blowers)
  • fire cabinet not installed for flammable liquids stored in restaurant
  • other

• Specify

PlayPlace Safety

• HS14-US Operational Procedures: Are operational and inspection procedures established, communicated, and implemented to promote the safety of PlayPlaces?

  Yes

  No

  N/A

• Select reasons

  Select annual inspection not completed or is not available equipment not inspected daily or in good repair equipment and flooring are not clean or odor free wipes available are not from approved suppliers corrective action plan not available wipes not available other

  • annual inspection not completed or is not available
  • equipment not inspected daily or in good repair
  • equipment and flooring are not clean or odor free
  • wipes available are not from approved suppliers
  • corrective action plan not available
  • wipes not available
  • other

• Specify

Chemical Safety

• HS15-US Is the Hazcom app available and accessible for all approved chemical products that are being used in the restaurant and have employees been trained on its use?

  Yes

  No

  N/A

• Select reasons

  Select Safety Data Sheets (SDS) electronic Hazcom app not present employees not trained how to read and use SDS other

  • Safety Data Sheets (SDS) electronic Hazcom app not present
  • employees not trained how to read and use SDS
  • other

• Specify

• HS16 -US Are only approved cleaning products/chemicals being used (from an approved supplier), properly stored, and in their original container/packaging?

  Yes

  No

  N/A

• Select reasons

  Select unapproved chemicals being used primary or secondary bottles and containers not properly labeled chemicals not stored properly chemicals not used properly other

  • unapproved chemicals being used
  • primary or secondary bottles and containers not properly labeled
  • chemicals not stored properly
  • chemicals not used properly
  • other

• Specify

Slip and Fall Prevention

• HS17-US Are floors clean and slip-resistant when walked on?

  Yes

  No

  N/A

• Select reasons

  Select interior flooring not in good repair/free of obstacles floors are not clean and slip resistant do not have a minimum of 4 'Caution Wet Floor' signs available 'Caution Wet Floor' signs not used appropriately or available in restaurant mop buckets contain cold/dirty water - cleaning solution is not being changed when appropriate other

  • interior flooring not in good repair/free of obstacles
  • floors are not clean and slip resistant
  • do not have a minimum of 4 'Caution Wet Floor' signs available
  • 'Caution Wet Floor' signs not used appropriately or available in restaurant
  • mop buckets contain cold/dirty water - cleaning solution is not being changed when appropriate
  • other

• Specify

• HS18-US Are exterior walkways, patios, parking lots, curbs, ramps, and driveways in good repair and free of obstacles and conditions in which a person could slip on or trip over?

  Yes

  No

  N/A

• Select reasons

  Select exterior walkways/parking lot not in good repair/free of obstacles debris, oil, ice or other obstacles and/or substances are present other

  • exterior walkways/parking lot not in good repair/free of obstacles
  • debris, oil, ice or other obstacles and/or substances are present
  • other

• Specify

Building Safety

• HS19-US Are self-serve ice machine storage bin lids (overhead style) correctly in place and not at risk of falling?

  Yes

  No

  N/A

• Select reasons

  Select ice machine lids at risk of falling ice machine lid is missing other

  • ice machine lids at risk of falling
  • ice machine lid is missing
  • other

• Specify

• HS20-US Are all flag poles, lot light poles, and sign poles, including their base plates and anchor bolts in good repair?

  Yes

  No

  N/A

• Select reasons

  Select flag poles, lot lights, sign poles not in good repair Base plates and anchor bolts not in good repair/covered by landscaping materials, debris or concrete other

  • flag poles, lot lights, sign poles not in good repair
  • Base plates and anchor bolts not in good repair/covered by landscaping materials, debris or concrete
  • other

• Specify

• HS21-US Are interior and exterior chairs and tables stable and free of conditions that could cause injury (e.g.: sharp edges, loose/missing hardware, cracks, corrosion, etc.)?

  Yes

  No

  N/A

• Select reasons

  Select interior and exterior chairs and tables are not stable and free of conditions that could cause injury (e.g. sharp edges, loose/missing hardware, cracks, corrosion, etc.) other

  • interior and exterior chairs and tables are not stable and free of conditions that could cause injury (e.g. sharp edges, loose/missing hardware, cracks, corrosion, etc.)
  • other

• Specify

• HS22-US Are the interior roof hatches equipped with internal ladders that have a railing or other handhold extending above the roof line to enable safe transfer from the ladder to the roof’s surface?

  Yes

  No

  N/A

• Select reasons

  Select interior roof hatches not equipped with internal ladder with railing or other handhold extending above the roof line other

  • interior roof hatches not equipped with internal ladder with railing or other handhold extending above the roof line
  • other

• Specify

Security

• HS23-US Are all outside delivery freezer door unit locking mechanisms locked and in good operating condition?

  Yes

  No

  N/A

• Select reasons

  Select outside delivery freezer door unit does not have a locking system that locks outside delivery freezer door is not locked during your visit outside delivery freezer missing or not in good condition key is inserted into the outdoor delivery freezer door when the manager is not present other

  • outside delivery freezer door unit does not have a locking system that locks
  • outside delivery freezer door is not locked during your visit
  • outside delivery freezer missing or not in good condition
  • key is inserted into the outdoor delivery freezer door when the manager is not present
  • other

• Specify

• HS24-US Do Drive-thru windows have locks that are in good operating condition that are secured when unattended?

  Yes

  No

  N/A

• Select reasons

  Select Drive-thru windows do not have locking latch/arm bars or they are broken, not maintained, or in good condition Drive-thru windows unable to close and lock Drive-thru windows not locked when unattended other

  • Drive-thru windows do not have locking latch/arm bars or they are broken, not maintained, or in good condition
  • Drive-thru windows unable to close and lock
  • Drive-thru windows not locked when unattended
  • other

• Specify

• HS25-US Is the back door equipped with an unobstructed and working external view device, i.e., peephole, flap, window, video monitor, etc., locked (except during deliveries and emptying trash), and alarmed when not in use?

  Yes

  No

  N/A

• Select reasons

  Select back door alarm is unarmed, missing or non-functional key is inserted into the back-door alarm box when the manager is not present back door not equipped with unobstructed and working view device/peephole/flap/monitor back door lock is missing or non-functional other

  • back door alarm is unarmed, missing or non-functional
  • key is inserted into the back-door alarm box when the manager is not present
  • back door not equipped with unobstructed and working view device/peephole/flap/monitor
  • back door lock is missing or non-functional
  • other

• Specify

• HS26-US Is there a safe, locked and functioning at all times, located in the manager’s office or other secure location?

  Yes

  No

  N/A

• Select reasons

  Select safe is not present safe is not locked and functioning properly safe is not in manager’s office or other secure location

  • safe is not present
  • safe is not locked and functioning properly
  • safe is not in manager’s office or other secure location

• HS27-US Is there a designated room/area to enable safe cash handling and housing of IT equipment?

  Yes

  No

  N/A

• Select reasons

  Select employees not responsible to count cash are inside the office room/area present but not able to safely handle cash no designated secured room for cash handling and security IT equipment room/area present but does not provide/enable safe housing of IT equipment other

  • employees not responsible to count cash are inside the office
  • room/area present but not able to safely handle cash
  • no designated secured room for cash handling and security IT equipment
  • room/area present but does not provide/enable safe housing of IT equipment
  • other

• Specify

• HS28-US Security Training: Has restaurant management and crew received security training?

  Yes

  No

  N/A

• Select reasons

  Select current security training plan not found or in place management and/or crew security training has not occurred as part of on-boarding or as accountabilities change management and/or crew have not undertaken Workplace Violence Prevention training managers do not know the contact details for local emergency services managers do not know purpose or how to use security equipment other

  • current security training plan not found or in place
  • management and/or crew security training has not occurred as part of on-boarding or as accountabilities change
  • management and/or crew have not undertaken Workplace Violence Prevention training
  • managers do not know the contact details for local emergency services
  • managers do not know purpose or how to use security equipment
  • other

• Specify

• HS29-US Security Procedures: Can restaurant management describe the proper security procedures to be followed?

  Yes

  No

  N/A

• Select reasons

  Select manager can’t explain the staggered open and closing procedures manager can’t produce a key to lock the restaurant manager is unable to lock the restaurant from inside and outside the restaurant incident reporting procedures are not followed or known incident local security policies and procedures are not known other

  • manager can’t explain the staggered open and closing procedures
  • manager can’t produce a key to lock the restaurant
  • manager is unable to lock the restaurant from inside and outside the restaurant
  • incident reporting procedures are not followed or known incident
  • local security policies and procedures are not known
  • other

• Specify

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• Name and Signature

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