• Conducted on:

  • Prepared by:


  • Is the floor of every work area maintained in a clean and, so far as possible, a dry condition?

  • Are aisles and passageways kept clear with no obstructions across or in aisles that could create a hazard and appropriately marked?

  • Is sufficient access and working space provided and maintained about all electrical equipment to permit ready and safe operations and maintenance (36”)?

Emergency Action Plan

  • Are exits clearly marked “EXIT” and exit routes adequately lit? Access/egress routes are clear and unobstructed?

  • Are the number of exit routes adequate? Are exits doors unlocked? Do exit route doors discharge to an open space that gives safe access?

  • Appropriate fire extinguishers are readily accessible; noted in good condition; tagged; and inspected (annual, monthly)?

  • Medical services and first aid readily are available? Are first-aid kits easily accessible to each work area, with necessary supplies available, periodically inspected and replenished as needed?

  • Emergency eye wash / shower facilities are located within the immediate work area where employees are exposed to corrosive materials?

  • Employee workstations are set so that employees would not become trapped or enclosed by material or equipment?

Fire Protection

  • Is any type of flammable storage / hot work exposure observed in the facility at the time of the survey?

  • Cylinders are stored properly (e.g. upright position, caps in place, protected from falling)?<br><br>

  • Oxygen is separated at least 20’ from fuel-gas cylinders or combustible materials (such as oil or grease)?<br><br>

  • Flashback arrestors are used on burning torches to prevent flashback into the compressed gas tanks?<br>

Machine Guarding & Lockout/Tagout (LOTO)

  • Is any type of machine safety / lockout-tagout exposure observed at the time of the survey?

  • Rotating or moving parts of equipment, chains, and gears properly guarded to prevent physical contact? Are all point-of-operation exposures properly guarded/protected?<br>

  • Are bench grinders guarded and compliant with OSHA standards [ work rest - 1/8-inch; adjustable tongue guard - 1/4-inch ] ?

  • LO/TO is performed correctly / using correct LO/TO equipment? This includes during set-ups

Personal Protective Equipment (PPE)

  • Are safety glasses used by employees while in the plant or manufacturing areas?

  • Are cut-resistant sleeves worn by all employees in the plant or manufacturing areas?

  • Gloves / hand protection are utilized as needed?<br>

  • Safety-toed shoes or boots are worn in the plant or manufacturing areas?<br>

Hazard Communication

  • Is any type of chemical / hazard communication exposure observed in the facility at the time of the survey?

  • Containers of hazardous chemicals in the workplace are labeled, tagged, or marked identifying the chemical it contains as well as the appropriate hazard warnings?<br><br>

  • Safety Data Sheets (SDSs) are in place for materials/chemicals on-site and are readily accessible to employees? <br>


  • Is any type of electrical exposure observed in the facility at the time of the survey?

  • Live electrical apparats have shields or guarding to prevent accidental contact?

  • Flexible cords and cables appeared in good condition (ground pin in place, free of splices, insulation)?<br><br>

  • Electrical-Additional Observation

Walking-Working Surfaces/Fall Protection

  • Is any type of walking-working surfaces / fall protection exposure observed in the facility at the time of the survey

  • Employees above four feet from the next level are protected from falling?<br>

  • Man-lifts, powered platforms, and/or vehicle-mounted work platforms are used with proper fall protection in place?<br>

  • Stairs/changes in elevation are marked/tread appears adequate?

  • Ladders used properly and is in adequate condition?

Material Handling / Powered Industrial Trucks (Forklifts)

  • Powered industrial trucks are inspected before each shift to ensure they are in proper working service? <br><br>

  • Have all authorized powered industrial truck drivers been trained and certified (machine-specific) within in the past 3 years?

  • Powered industrial truck(s) were operated in a safe manner (i.e. seat belt, safe speed, clear view etc.) at time of evaluation?<br><br>

  • Docks locks appeared to be in use when loading or unloading trucks?

Tools & Equipment

  • Were any type of tools or equipment observed in use during the survey?

  • Hand tools appear to be in good working order?<br><br>

  • Hand / powered tools have proper guarding?

  • Is compressed air (designed for cleaning purposes) restricted at 30 psi?<br>

  • Tools & Equipment-Additional Observation

Additional Observations

  • Is there any type of exposure not already addressed in this report?

Overall Comments / Notes

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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.