Title Page

  • Site conducted

  • Safety / Emergency Responder / Team Leader

  • Conducted on (Date and Time)

  • Name of Auditor

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Section 1 - Housekeeping

  • 1.0 Select Department

  • 1.1 Are walkways, aisles, and working surfaces free of slip hazards (such as oil, grease, water, ink)?

  • 1.2 Are walkways, aisles, working surfaces, exits, and doors free of obstructions (such as boxes, equipment, materials, or tools)?

  • 1.3 Are traffic devices (such as a mirror, strobe light, or traffic cones) available for congested areas?

  • 1.4 Are pedestrian traffic signs and markings easy to see?

  • 1.5 Are there any blown lights in the work area?

  • 1.6 Are Exit routes clearly marked “Exit,” and show the direction of travel to an Exit?

  • 1.7 Are hoses and electrical cords positioned out of walk-ways to prevent injuries?

  • 1.8 Are team members familiar with emergency Assembly Points?

  • 1.9 Nominal Score = 8 Points, 10 Points = Max Score

Section 2.0 - Fire and Chemicals

  • 2.1 Are fire extinguishers in the area charged and in place?

  • 2.2 Has each fire extinguisher been inspected and tagged for the month?

  • 2.3 Are fire extinguishers blocked?

  • 2.4 Are team members familiar with AED location(s)?

  • 2.5 Has the AED been checked for use?

  • 2.6 Are Eye Wash Inspection Tag(s) current?

  • 2.7 Are employee familiar with the First Aid Kit location?

  • 2.8 Are flammable and combustible materials stored as required by regulatory standards?

  • 2.9 Are drip pans and guards in place to catch spills?

  • 2.10 Nominal Score = 8 Points, 10 Points = Max Score

Section 3 - Guarding

  • 3.1 Are barriers in place to keep un-authorized team member(s) and visitors away from heavy machinery and materials?

  • 3.2 Are machine guards in place to protect workers?

  • 3.3 Are there any machine guards that appear to broken, loose, or in need of repair?

  • 3.4 Is the ALTERNATE Energy Plan / Tool visible and available for clearing a jam / servicing?

  • 3.5 Is the LOTO program available for review for the operator?

  • 3.6 Are ALTERNATE Energy Storage Tools within the immediate work area?

  • 3.7 Have team mates been issued their own lock?

  • 3.8 Have team mates completed LOTO training?

  • 3.9 Nominal Score = 24 Points, 30 Points = Max Score

Section 4 - Fall Protection

  • 4.1 Are ladders, step-ladders, or stools serviceable (do not require repairs or removal)?

  • 4.2 Are serviceable ladders, step-ladders, or stools stored and secured in specific locations?

  • 4.3 Have ladders, step-ladders, and tools been tagged and inspected for Safe Use?

  • 4.4 Have holes (larger than 2 inches) on walking or working surfaces been covered and will support twice the intended load?

  • 4.5 Are guard rails serviceable at all working levels?

  • 4.6 Have any guard rails been damaged or may be missing at any level?

  • 4.7 Have team mates received training for any work that may be performed 4 feet above another working surface or level?

  • 4.8 Have team mates received training for any specialty equipment (such as scissor or boom lift)?

  • 4.9 Have spills been cleaned on walking and working surfaces?

  • 4.10 Are there any slip / trip hazards?

  • 4.11 Nominal Score = 16 Points, 20 Points = Max Score

Section 5.0 - Electrical

  • 5.1 Have electrical cords been inspected for the month?

  • 5.2 Are GFI(s) / GFCI(s) in serviceable condition?

  • 5.3 Are ground pins available on extension cords?

  • 5.4 Have extension cords been installed to serve as permanent wiring?

  • 5.5 Has the machine / equipment been locked and tagged out for maintenance and repairs?

  • 5.6 Are Lockout / Tagout procedures available or posted on the machine or equipment?

  • 5.7 Are there ALTERNATE Energy plans or procedures used for routine, cleaning, jams, and repetitive task(s)?

  • 5.8 Has the Exclusive Person or Operator been identified if the ALTERNATE Energy Storage Procedure?

  • 5.9 Are the controls for the equipment or machine under control of the Exclusive Person?

  • 5.10 Has the ALTERNATE Energy Storage decision tree been used and are hand tools available?

  • 5.11 Is the EST Yellow Tag visible on controls?

  • 5.12 Are there any additional hazards? If yes, take a picture and communicate it to Supervisor.

  • 5.13 Nominal Score = 8 Points, 10 Points = Max Score

Section 6.0 - Forklift / Crane / Material Handling and Storage

  • 6.1 Have forklifts been inspected prior to shift change?

  • 6.2 Have 3rd party vendors made maintenance records available?

  • 6.3 Have forklift operators completed training?

  • 6.4 Have crane operators completed training?

  • 6.5 Have crane operators inspected hoisting equipment (such as slings and connectors)?

  • 6.6 Are crane records available for review?

  • 6.7 Are signs, cones, barricades, or spotters used for overhead work activities?

  • 6.8 Are crane operators, signal persons, and riggers identified with HI-VIZ PPE?

  • 6.9 Are materials stored in the designated areas to prevent falls?

  • 6.10 Has a BLUE CARD been completed for each shift for Overhead Work?

  • 6.11 Nominal Score = 8 Points, 20 Points = Max Score

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