Internal Safety Audit - Stores 875e-2.4

• Store Number

• Store Manager Name

• Conducted on

  Date

• Audit Prepared by

• Location
  Address

Courtesy Booth

• Have Courtesy Booth employees received training as to what to do in case of robbery? Verify documentation.

  Yes

  No

  N/A

• Is the floor free of debris or excess liquids (slip/trip hazards)?

  Yes

  No

  N/A

• Are anti-fatigue mats provided for the Courtesy Booth employees?

  Yes

  No

  N/A

• Are the Lock Out Tag Out log sheets up to date with correct information being recorded on them? Look for missing data.

  Yes

  No

  N/A

• Review Lock Out Tag Out devices. Do they appear to be in proper working order?

  Yes

  No

  N/A

• Is the department free of obvious electrical hazards including, but not limited to electrical panels, missing or improper labeling, frayed wires, missing ground plugs, broken light switches, etc.?

  Yes

  No

  N/A

• Are there any additional electrical concerns? If yes please list.

  yes

  no

• Are electrical panels free of obstructions?

  Yes

  No

  N/A

• Are first aid kits stocked with at least minimum required items?

  Yes

  No

  N/A

• Are there any safety related concerns present in the department that are not listed in the audit? If yes, explain.

  yes

  no

• Are there any additional safety concerns with this department?

  yes

  no

Check Out Area

• Are employees that are working outside in areas off of the sidewalk wearing the provided ANSI Class II reflective vests?

  Yes

  No

  N/A

• Are exits/emergency exits free from obstructions?

  Yes

  No

  N/A

• Are the floors free of any apparent slip/trip hazards? If no, describe. Check entry ways inside and out in addition to floor up front.

  Yes

  No

  N/A

• Are cashiers using proper technique to scan items? They should be using the reach and feed method of picking up the item with one hand, passing it over the scanner to the other hand and placing the item on the register belt.

  Yes

  No

  N/A

• Are anti-fatigue mats provided for the Cashiers?

  Yes

  No

  N/A

• Are chemicals used in the department contained in properly labeled bottles? Be sure to check maintenance closet and utility carts in addition to the checkout area.

  Yes

  No

  N/A

• Is the department adhering to the policy of not removing chemicals from the shelves? Be sure to check maintenance closet and utility carts in addition to the checkout area.

  Yes

  No

  N/A

• Is the department free of obvious electrical hazards including, but not limited to electrical panels, missing or improper labeling, frayed wires, missing ground plugs, broken light switches, etc.? (Check mart carts, soda coolers, kiddie rides outside, etc.)

  Yes

  No

  N/A

• Are there any additional electrical concerns? If yes please list.

  yes

  no

• Are electrical panels free of obstructions?

  Yes

  No

  N/A

• Are there any safety related concerns present in the department that are not listed in the audit? If yes, explain.

  yes

  no

• Are there any additional safety concerns with this department?

  yes

  no

• Additional notes

Grocery Department

• Is the sales floor free of debris and excess liquids (slip/trip hazards)?

  Yes

  No

  N/A

• Is the back room area free of debris and excess liquids (slip/trip hazards)?

  Yes

  No

  N/A

• Are display media, shelving, racks, etc. in proper repair as to not cause injury to an employee? Look for broken parts, loose shelving, protruding objects, etc. If no, explain.

  Yes

  No

  N/A

• Are items on shelving stacked properly and items stored on pallets in racking shrink wrapped properly so as to not fall on employees?

  Yes

  No

  N/A

• Are gigs and pallets in proper working condition?

  Yes

  No

  N/A

• Does Powered Industrial Equipment appear to be in proper working condition including having warning labels and data plates intact?

  Yes

  No

  N/A

• Are dock plates stored securely when not in use?

  Yes

  No

  N/A

• Are chemicals used in the department contained in properly labeled bottles?

  Yes

  No

  N/A

• Is the department adhering to the policy of not removing chemicals from the shelves?

  Yes

  No

  N/A

• Look at the Powered Industrial Truck Inspection form located near the manager office. Interview the employee that conducted the inspection of the equipment for that day. Ask the employee what steps that they take to inspect the equipment? Does the employee appear to inspect the equipment properly?

  Yes

  No

  N/A

• Is the department free of obvious electrical hazards including, but not limited to electrical panels, missing or improper labeling, frayed wires, missing ground plugs, broken light switches, etc.?

  Yes

  No

  N/A

• Are there any additional electrical concerns? If yes please list.

  yes

  no

• Are electrical panels free of obstructions?

  Yes

  No

  N/A

• Are there any safety related concerns present in the department that are not listed in the audit? If yes, explain.

  yes

  no

• Are there any additional safety concerns with this department?

  yes

  no

Dairy Department

• Is the cooler and back room area free of debris and excess liquids (slip/trip hazards)?

  Yes

  No

  N/A

• Are cooler and freezer doors free of obstructions, allowing for easy access by employees from either side?

  Yes

  No

  N/A

• Are latches on cooler or freezer doors in proper working order so as to prevent entrapment?<br>

  Yes

  No

  N/A

• Is there any excess ice buildup in any of the freezers either on the ceiling or the floor, including around doorways and the threshold?

  yes

  no

• Are display cases, racks, spot coolers, etc. are in in proper repair as to not cause injury to an employee? Look for broken parts, loose shelving, protruding objects, frayed wires, etc. If no, explain.

  Yes

  No

  N/A

• Are chemicals used in the department contained in properly labeled bottles?

  Yes

  No

  N/A

• Is the department adhering to the policy of not removing chemicals from the shelves?

  Yes

  No

  N/A

• Are items stacked properly on shelving so as to not fall on employees, while also maintaining an 18 inch plane of clearance around room from sprinkler heads?

  Yes

  No

  N/A

• Is the department free of obvious electrical hazards including, but not limited to electrical panels, missing or improper labeling, frayed wires, missing ground plugs, broken light switches, etc.?

  Yes

  No

  N/A

• Are there any additional electrical concerns? If yes please list.

  yes

  no

• Are electrical panels free of obstructions?

  Yes

  No

  N/A

• Are there any safety related concerns present in the department that are not listed in the audit? If yes, explain.

  yes

  no

• Are there any additional safety concerns with this department?

  yes

  no

Deli/Seafood Department

• Is the cooler and back room area free of debris and excess liquids (slip/trip hazards)?

  Yes

  No

  N/A

• Are cooler and freezer doors free of obstructions, allowing for easy access by employees from either side?

  Yes

  No

  N/A

• Are latches on cooler or freezer doors in proper working order so as to prevent entrapment?<br>

  Yes

  No

  N/A

• Are display cases, racks, spot coolers, etc. are in in proper repair as to not cause injury to an employee? Look for broken parts, loose shelving, protruding objects, frayed wires, etc. If no, explain.

  Yes

  No

  N/A

• Are chemicals used in the department contained in properly labeled bottles?

  Yes

  No

  N/A

• Are chemicals being stored properly in the department (they should never stored above food)?<br>

  Yes

  No

  N/A

• Is PPE available in the department and in good working condition, (cutting glove not frayed, splash goggles with clean and clear lenses)?

  Yes

  No

  N/A

• Is the department adhering to the policy of not removing chemicals from the shelves?

  Yes

  No

  N/A

• Are items stacked properly on shelving so as to not fall on employees, while also maintaining an 18 inch plane of clearance around room from sprinkler heads?

  Yes

  No

  N/A

• Are all knives being stored properly when not in use? Look for unattended knives at various work stations.

  Yes

  No

  N/A

• Are heat resistant gloves in good repair and available for use for the oven, lobster steamer, and microwave?

  Yes

  No

  N/A

• Are employees closing the deli slicer blade prior to removing product from the slicer and also when not in use?

  Yes

  No

  N/A

• Have an employee explain how to break down and clean the deli slicer. Can the employee describe the steps, including the use of cut resistant gloves on both hands to clean he blade?

  Yes

  No

  N/A

• Are first aid kits stocked with at least minimum required items?

  Yes

  No

  N/A

• Is the department free of obvious electrical hazards including, but not limited to electrical panels, missing or improper labeling, frayed wires, missing ground plugs, broken light switches, etc.?

  Yes

  No

  N/A

• Are there any additional electrical concerns? If yes please list.

  yes

  no

• Are electrical panels free of obstructions?

  Yes

  No

  N/A

• Are safety signs and labels in place and intact? This includes minimum age usage signs, warning labels, exit signs, etc. Please note any deficiencies.

  Yes

  No

  N/A

• Are there any safety related concerns present in the department that are not listed in the audit? If yes, explain.

  yes

  no

• Are there any additional safety concerns with this department?

  yes

  no

Meat Department

• Is the cooler and back room area free of debris and excess liquids (slip/trip hazards)?

  Yes

  No

  N/A

• Are cooler and freezer doors free of obstructions, allowing for easy access by employees from either side?

  Yes

  No

  N/A

• Are latches on cooler or freezer doors in proper working order so as to prevent entrapment?<br>

  Yes

  No

  N/A

• Is there any excess ice buildup in any of the freezers either on the ceiling or the floor, including around doorways and the threshold?

  yes

  no

• Are display cases, racks, spot coolers, etc. are in in proper repair as to not cause injury to an employee? Look for broken parts, loose shelving, protruding objects, frayed wires, etc. If no, explain.

  Yes

  No

  N/A

• Is the band saw in operation at the time of the audit?

  yes

  no

• Is the band saw being operated properly, including using provided guards, pusher plate if cutting smaller chunks of meat, and keeping blade guard as close as possible to portion of meat being cut?

  Yes

  No

  N/A

• Is the saw shut off, with blade guard fully closed?

  Yes

  No

  N/A

• Are items stacked properly on shelving so as to not fall on employees, while also maintaining an 18 inch plane of clearance around room from sprinkler heads?

  Yes

  No

  N/A

• Are chemicals used in the department contained in properly labeled bottles?

  Yes

  No

  N/A

• Is the department adhering to the policy of not removing chemicals from the shelves?

  Yes

  No

  N/A

• Is PPE available in the department and in good working condition, (cutting glove not frayed, splash goggles with clean and clear lenses)?

  Yes

  No

  N/A

• Are chemicals being stored properly in the department (they should never stored above food)?<br>

  Yes

  No

  N/A

• Are all knives being stored properly when not in use? Look for unattended knives at various work stations.

  Yes

  No

  N/A

• Is the department free of obvious electrical hazards including, but not limited to electrical panels, missing or improper labeling, frayed wires, missing ground plugs, broken light switches, etc.?

  Yes

  No

  N/A

• Are there any additional electrical concerns? If yes please list.

  yes

  no

• Are electrical panels free of obstructions?

  Yes

  No

  N/A

• Are safety signs and labels in place and intact? This includes minimum age usage signs, warning labels, exit signs, etc. Please note any deficiencies.

  Yes

  No

  N/A

• Are there any safety related concerns present in the department that are not listed in the audit? If yes, explain.

  yes

  no

• Are there any additional safety concerns with this department?

  yes

  no

Produce Department

• Is the cooler, prep room, and back room area free of debris and excess liquids (slip/trip hazards)?

  Yes

  No

  N/A

• Are cooler doors free of obstructions, allowing for easy access by employees from either side?

  Yes

  No

  N/A

• Are latches on cooler or freezer doors in proper working order so as to prevent entrapment?<br>

  Yes

  No

  N/A

• Are display cases, racks, spot coolers, etc. are in in proper repair as to not cause injury to an employee? Look for broken parts, loose shelving, protruding objects, frayed wires, etc. If no, explain.

  Yes

  No

  N/A

• Are items stacked properly on shelving and on pallets so as to not fall on employees, while also maintaining an 18 inch plane of clearance around room from sprinkler heads?

  Yes

  No

  N/A

• Are chemicals used in the department contained in properly labeled bottles?

  Yes

  No

  N/A

• Is PPE available in the department and in good working condition, (cutting glove not frayed, splash goggles with clean and clear lenses)?

  Yes

  No

  N/A

• Are chemicals being stored properly in the department (they should never stored above food)?<br>

  Yes

  No

  N/A

• Is the department adhering to the policy of not removing chemicals from the shelves?

  Yes

  No

  N/A

• Are all knives being stored properly when not in use? Look for unattended knives at various work stations.

  Yes

  No

  N/A

• Is the department free of obvious electrical hazards including, but not limited to electrical panels, missing or improper labeling, frayed wires, missing ground plugs, broken light switches, etc.?

  Yes

  No

  N/A

• Are there any additional electrical concerns? If yes please list.

  yes

  no

• Are electrical panels free of obstructions?

  Yes

  No

  N/A

• Are safety signs and labels in place and intact? This includes minimum age usage signs, warning labels, exit signs, etc. Please note any deficiencies.

  Yes

  No

  N/A

• Are there any safety related concerns present in the department that are not listed in the audit? If yes, explain.

  yes

  no

• Are there any additional safety concerns with this department?

  yes

  no

Bakery Department if applicable

• Does this store have a Bakery Department?

  yes

  no

• Is the cooler and back room area free of debris and excess liquids (slip/trip hazards)?

  Yes

  No

  N/A

• Are cooler and freezer doors free of obstructions, allowing for easy access by employees from either side?

  Yes

  No

  N/A

• Are latches on cooler or freezer doors in proper working order so as to prevent entrapment?<br>

  Yes

  No

  N/A

• Is there any excess ice buildup in any of the freezers either on the ceiling or the floor, including around doorways and the threshold?

  yes

  no

• Are display cases, racks, spot coolers, etc. are in in proper repair as to not cause injury to an employee? Look for broken parts, loose shelving, protruding objects, frayed wires, etc. If no, explain.

  Yes

  No

  N/A

• Are items stacked properly on shelving so as to not fall on employees, while also maintaining an 18 inch plane of clearance around room from sprinkler heads?

  Yes

  No

  N/A

• Are chemicals used in the department contained in properly labeled bottles?

  Yes

  No

  N/A

• Is PPE available in the department and in good working condition, (cutting glove not frayed, splash goggles with clean and clear lenses)?

  Yes

  No

  N/A

• Are chemicals being stored properly in the department (they should never stored above food)?<br>

  Yes

  No

  N/A

• Is the department adhering to the policy of not removing chemicals from the shelves?

  Yes

  No

  N/A

• Are heat resistant gloves in good repair and available for use for the oven?

  Yes

  No

  N/A

• Are all knives being stored properly when not in use? Look for unattended knives at various work stations.

  Yes

  No

  N/A

• Does the department have a first aid kit?

  yes

  no

• Are first aid kits stocked with at least minimum required items?

  Yes

  No

  N/A

• Is the department free of obvious electrical hazards including, but not limited to electrical panels, missing or improper labeling, frayed wires, missing ground plugs, broken light switches, etc.?

  Yes

  No

  N/A

• Are there any additional electrical concerns? If yes please list.

  yes

  no

• Are electrical panels free of obstructions?

  Yes

  No

  N/A

• Are safety signs and labels in place and intact? This includes minimum age usage signs, warning labels, exit signs, etc. Please note any deficiencies.

  Yes

  No

  N/A

• Are there any safety related concerns present in the department that are not listed in the audit? If yes, explain.

  yes

  no

• Are there any additional safety concerns with this department?

  yes

  no

Kitchen/Cafe Department if applicable

• Does this store have a Kitchen and/or cafe?

  yes

  no

• Is the cooler and back room area free of debris and excess liquids (slip/trip hazards)?

  Yes

  No

  N/A

• Are display cases, racks, spot coolers, etc. are in in proper repair as to not cause injury to an employee? Look for broken parts, loose shelving, protruding objects, frayed wires, etc. If no, explain.

  Yes

  No

  N/A

• Are latches on cooler or freezer doors in proper working order so as to prevent entrapment?<br>

  Yes

  No

  N/A

• Is equipment in proper repair so as to not injure an employee?

  Yes

  No

  N/A

• Are items stacked properly on shelving so as to not fall on employees, while also maintaining an 18 inch plane of clearance around room from sprinkler heads?

  Yes

  No

  N/A

• Are chemicals used in the department contained in properly labeled bottles?

  Yes

  No

  N/A

• Is PPE available in the department and in good working condition, (cutting glove not frayed, splash goggles with clean and clear lenses)?

  Yes

  No

  N/A

• Are chemicals being stored properly in the department (they should never stored above food)?<br>

  Yes

  No

  N/A

• Is the department adhering to the policy of not removing chemicals from the shelves?

  Yes

  No

  N/A

• Are heat resistant gloves in good repair and available for use for the oven and microwave?

  Yes

  No

  N/A

• Are all knives being stored properly when not in use? Look for unattended knives at various work stations.

  Yes

  No

  N/A

• Does the department have a first aid kit?

  yes

  no

• Are first aid kits stocked with at least minimum required items?

  Yes

  No

  N/A

• Is the department free of obvious electrical hazards including, but not limited to electrical panels, missing or improper labeling, frayed wires, missing ground plugs, broken light switches, etc.?

  Yes

  No

  N/A

• Are there any additional electrical concerns? If yes please list.

  yes

  no

• Are electrical panels free of obstructions?

  Yes

  No

  N/A

• Are safety signs and labels in place and intact? This includes minimum age usage signs, warning labels, exit signs, etc. Please note any deficiencies.

  Yes

  No

  N/A

• Are there any safety related concerns present in the department that are not listed in the audit? If yes, explain.

  yes

  no

• Are there any additional safety concerns with this department?

  yes

  no

Overall Store Items

• Do compressor room, HVAC room, and other areas that are designated as "Authorized Personnel Only" appear to be free of obvious hazards?

  Yes

  No

  N/A

• Does the compressor room have copies of the SDS for refrigeration related chemicals?

  Yes

  No

  N/A

• Is the HVAC room free of obvious electrical hazards including, but not limited to electrical panels, missing or improper labeling, frayed wires, missing ground plugs, broken light switches, etc.? Check mart cart plugs and cords.

  Yes

  No

  N/A

• Are there any additional electrical concerns? If yes please list.

  yes

  no

• Is the employee bulletin board up to date and contain pertinent safety related information?

  Yes

  No

  N/A

• Is the HazCom/SDS binder and the I2P2/Emergency action plan binder both located in the lunch room and made easily accessible?

  Yes

  No

  N/A

• Is the eyewash station being checked on a monthly basis and filled to at least to the minimum level line?

  Safe

  At Risk

  N/A

• Is the correct PPE being used for different job tasks? If no, please note department, PPE, and task.

  Yes

  No

  N/A

• Are fire exits unblocked, maintaining a minimum of 28 inches of clearance?<br>

  Safe

  At Risk

  N/A

• Do fire exit work properly, open freely, and alarm sounds when opened?<br>

  Safe

  At Risk

  N/A

• Are fire extinguishers being checked on a monthly basis?

  Yes

  No

  N/A

• Are all Powered Industrial Equipment being inspected on a daily basis and being recorded on the log sheet?

  Yes

  No

  N/A

• Are guardrails in place on the tops of coolers or loft areas and include a swing gate if ladder access is utilized?

  Yes

  No

  N/A

• Are staircases free of slip/trip hazards? If no, please note location and take photo of condition.

  Yes

  No

  N/A

• Are step stools in proper working order?

  Yes

  No

  N/A

• Are ladders in proper working order?

  Yes

  No

  N/A

• Are there any safety related concerns present that are not listed in the audit? If yes, explain.

  yes

  no

• Are there any additional safety concerns with this department?

  yes

  no

Interview #1 - Non-management Employee

• Name of interviewed employee

• Department Employee works in.

• Do you have any concerns in regards to safety that you feel we need to address? If yes, please describe in detail.

  yes

  no

• Have you spoken to a manager about these concerns?

  yes

  no

• Were these concerns that you raised addressed by your manager?

  Yes

  No

  N/A

• Have you received any of the following training? Select yes if training was received and employee has good knowledge? Select no if employee does not display good working knowledge. Select N/A if the training type does not apply.
  

• Has the employee received the chemical training, including receiving a copy of the chemical training booklet?<br>

  Yes

  No

  N/A

• Can the employee explain what a Safety Data Sheet (SDS) is?

  Yes

  No

  N/A

• Using the pictogram cards, can the employee identify a few pictograms successfully?<br>

  Yes

  No

  N/A

• If there were an emergency situation involving another employee, can the employee provide some explanation as to how they would properly assist in handling the situation?

  Yes

  No

  N/A

• Can the employee explain the location of and how to use the eyewash station?<br>

  Yes

  No

  N/A

• Training on how to lift items? Can the employee demonstrate proper lifting techniques?

  Yes

  No

  N/A

• Emergency Evacuation training? What is the designated area that you need to report to, using the quickest way out, and more importantly why do you need to report there?

  Yes

  No

  N/A

• Compactor use, if over 18? Employee should know about age restriction of 18 years or older, close door prior to turning on the compactor, and never to climb in the compactor.

  Yes

  No

  N/A

• Knife training? If employee is not trained to use a knife as part of the job description, please select N/A.

  Yes

  No

  N/A

• Have the employee explain the important training points regarding knife use. Does the employee display good knowledge? The employee should be able to explain the use of a cut resistant glove, to never leave a knife laying out unattended, and also how to clean the knife properly.

  Yes

  No

  N/A

• Lock Out Tag Out trained?

  yes

  no

• Have employee demonstrate LOTO procedure. Does the employee display good working knowledge of the program? Ask the employee a few questions about what equipment they lock out and about the process.

  Yes

  No

  N/A

• Powered Industrial Equipment trained?

  yes

  no

• Have employee describe the training that they received and how long the session was. Does the employee appear competent to use the equipment? Some items they should be able to discuss are stability triangle and weight capacity.

  Yes

  No

  N/A

• Has the employee received any other safety related training? If yes, please list additional training. Additional training can include Utility Knife Training, Step Stool Use, other department specific training, etc.

  yes

  no

• Does the employee seem knowledgeable in regards to his/her training?<br>

  Yes

  No

  N/A

• If there was a small amount of blood spilled on the floor, would you clean it up?

  yes

  no

• What would you do? Note answer. Answer should be inform a manager.

• Inform the employee that they are not authorized to clean up blood and that they must inform a manager if they encounter a blood spill or any other accident.

• Yes

  No

  N/A

Interview #2 - Non-management Employee

• Name of interviewed employee

• Department Employee works in.

• Do you have any concerns in regards to safety that you feel we need to address? If yes, please describe in detail.

  yes

  no

• Have you spoken to a manager about these concerns?

  yes

  no

• Were these concerns that you raised addressed by your manager?

  Yes

  No

  N/A

• Have you received any of the following training? Select yes if training was received and employee has good knowledge? Select no if employee does not display good working knowledge. Select N/A if the training type does not apply.
  

• Has the employee received the chemical training, including receiving a copy of the chemical training booklet?<br>

  Yes

  No

  N/A

• Can the employee explain what a Safety Data Sheet (SDS) is?

  Yes

  No

  N/A

• Using the pictogram cards, can the employee identify a few pictograms successfully?<br>

  Yes

  No

  N/A

• If there were an emergency situation involving another employee, can the employee provide some explanation as to how they would properly assist in handling the situation?

  Yes

  No

  N/A

• Can the employee explain the location of and how to use the eyewash station?<br>

  Yes

  No

  N/A

• Training on how to lift items? Can the employee demonstrate proper lifting techniques?

  Yes

  No

  N/A

• Emergency Evacuation training? What is the designated area that you need to report to, using the quickest way out, and more importantly why do you need to report there?

  Yes

  No

  N/A

• Compactor use, if over 18? Employee should know about age restriction of 18 years or older, close door prior to turning on the compactor, and never to climb in the compactor.

  Yes

  No

  N/A

• Knife training? If employee is not trained to use a knife as part of the job description, please select N/A.

  Yes

  No

  N/A

• Have the employee explain the important training points regarding knife use. Does the employee display good knowledge? The employee should be able to explain the use of a cut resistant glove, to never leave a knife laying out unattended, and also how to clean the knife properly.

  Yes

  No

  N/A

• Lock Out Tag Out trained?

  yes

  no

• Have employee demonstrate LOTO procedure. Does the employee display good working knowledge of the program? Ask the employee a few questions about what equipment they lock out and about the process.

  Yes

  No

  N/A

• Powered Industrial Equipment trained?

  yes

  no

• Have employee describe the training that they received and how long the session was. Does the employee appear competent to use the equipment? Some items they should be able to discuss are stability triangle and weight capacity.

  Yes

  No

  N/A

• Has the employee received any other safety related training? If yes, please list additional training. Additional training can include Utility Knife Training, Step Stool Use, other department specific training, etc.

  yes

  no

• Does the employee seem knowledgeable in regards to his/her training?<br>

  Yes

  No

  N/A

• If there was a small amount of blood spilled on the floor, would you clean it up?

  yes

  no

• What would you do? Note answer. Answer should be inform a manager.

• Inform the employee that they are not authorized to clean up blood and that they must inform a manager if they encounter a blood spill or any other accident.

Interview #3 - Non-management Employee

• Name of interviewed employee

• Department Employee works in.

• Do you have any concerns in regards to safety that you feel we need to address? If yes, please describe in detail.

  yes

  no

• Have you spoken to a manager about these concerns?

  yes

  no

• Were these concerns that you raised addressed by your manager?

  Yes

  No

  N/A

• Have you received any of the following training? Select yes if training was received and employee has good knowledge? Select no if employee does not display good working knowledge. Select N/A if the training type does not apply.
  

• Has the employee received the chemical training, including receiving a copy of the chemical training booklet?<br>

  Yes

  No

  N/A

• Can the employee explain what a Safety Data Sheet (SDS) is?

  Yes

  No

  N/A

• Using the pictogram cards, can the employee identify a few pictograms successfully?<br>

  Yes

  No

  N/A

• If there were an emergency situation involving another employee, can the employee provide some explanation as to how they would properly assist in handling the situation?

  Yes

  No

  N/A

• Can the employee explain the location of and how to use the eyewash station?<br>

  Yes

  No

  N/A

• Training on how to lift items? Can the employee demonstrate proper lifting techniques?

  Yes

  No

  N/A

• Emergency Evacuation training? What is the designated area that you need to report to, using the quickest way out, and more importantly why do you need to report there?

  Yes

  No

  N/A

• Compactor use, if over 18? Employee should know about age restriction of 18 years or older, close door prior to turning on the compactor, and never to climb in the compactor.

  Yes

  No

  N/A

• Knife training? If employee is not trained to use a knife as part of the job description, please select N/A.

  Yes

  No

  N/A

• Have the employee explain the important training points regarding knife use. Does the employee display good knowledge? The employee should be able to explain the use of a cut resistant glove, to never leave a knife laying out unattended, and also how to clean the knife properly.

  Yes

  No

  N/A

• Lock Out Tag Out trained?

  yes

  no

• Have employee demonstrate LOTO procedure. Does the employee display good working knowledge of the program? Ask the employee a few questions about what equipment they lock out and about the process.

  Yes

  No

  N/A

• Powered Industrial Equipment trained?

  yes

  no

• Have employee describe the training that they received and how long the session was. Does the employee appear competent to use the equipment? Some items they should be able to discuss are stability triangle and weight capacity.

  Yes

  No

  N/A

• Has the employee received any other safety related training? If yes, please list additional training. Additional training can include Utility Knife Training, Step Stool Use, other department specific training, etc.

  yes

  no

• Does the employee seem knowledgeable in regards to his/her training?<br>

  Yes

  No

  N/A

• If there was a small amount of blood spilled on the floor, would you clean it up?

  yes

  no

• What would you do? Note answer. Answer should be inform a manager.

• Inform the employee that they are not authorized to clean up blood and that they must inform a manager if they encounter a blood spill or any other accident.

Manager Interview - This interview is to be conducted with a Blood Pathogen Trained Manager?

• Name and position of manager

• Do you have any concerns in regards to safety that you feel we need to address? If yes, please describe in detail.

  yes

  no

• Have you spoken your manager or supervisor about these concerns?

  yes

  no

• Were these concerns that you raised addressed by your manager?

  Yes

  No

  N/A

• Have you received any of the following training? Select yes if training was received and employee has good knowledge? Select no if employee does not display goo working knowledge. Select N/A if the training type does not apply.
  

• Has the employee received the chemical training, including receiving a copy of the chemical training booklet?<br>

  Yes

  No

  N/A

• Can the employee explain what a Safety Data Sheet (SDS) is?

  Yes

  No

  N/A

• Using the pictogram cards, can the employee identify a few pictograms successfully?<br>

  Yes

  No

  N/A

• If there were an emergency situation involving another employee, can the employee provide some explanation as to how they would properly assist in handling the situation?

  Yes

  No

  N/A

• Can the employee explain the location of and how to use the eyewash station?<br>

  Yes

  No

  N/A

• Training on how to lift items? Does the employee seem knowledgeable on the subject?

  Yes

  No

  N/A

• How was the Lifting Training conducted and what type of information did your manager/trainer give you? Each employee should have received verbal instruction along with a booklet on the subject.

• Emergency Evacuation training? What is the designated area that you need to report to, using the quickest way out, and as a manager what is your responsibility during an evacuation?

  Yes

  No

  N/A

• Compactor use, if over 18? Employee should know about age restriction of 18 years or older, close door prior to turning on the compactor, and never to climb in the compactor.

  Yes

  No

  N/A

• Ask the Manager what he/she would do in the event of a blood spill. Is the manager Able to accurately describe the steps on how to clean up the blood?

  Yes

  No

  N/A

• Ask the manager if they are Lock out Tag out trained. Have the manager describe the Lock out Tag out process as part of the clean up of blood on equipment that requires LOTO as part of the cleaning process. Can they accurately describe the LOTO procedure?

  Yes

  No

  N/A

• Powered Industrial Equipment trained?

  yes

  no

• Have employee describe the training that they received and how long the session was. Does the employee appear competent to use the equipment? Some items they should be able to discuss are stability triangle and weight capacity.

  Yes

  No

  N/A

Safety Files and Training Documentation

• The safety files and training records should be up to date and in a logical order. Please review the file system with the manager. Look for missing or unsigned records. How would you rate the record keeping and organization of the files? 1 = lowest (no organization, missing or hard to find records) 5 = highest (some minor issues, but otherwise in great order)

• Review the OSHA 300 logs for injuries this year and last year. Are the managers accurately recording the injuries on the log?<br>

  Yes

  No

  N/A

• How many injuries are recorded on the OSHA 300 log?

• Review the injury investigation file. Is the manager conducting adequate injury investigations and providing corrective actions?

  Yes

  No

  N/A

• Review the Safety Employee Warning Notice file. How many warning notices for safety violations have been issued for this year?

• Are the employee training forms in good order. Spot check the employee training records to verify that training records are in good order and filled out properly.

  Yes

  No

  N/A

• Is the Blood Borne Pathogen Authorized user list up to date with the most current managers listed?

  Yes

  No

  N/A

• Is there a copy of the Blood Borne Pathogen knowledge test on file for each authorized manager? If no, list missing names or other discrepancies.<br>

  Yes

  No

  N/A

• Review the chemical training files. Spot check 2 departments and verify that the revised chemical training had been completed for active associates. Is the training up to date?

  Yes

  No

  N/A

• Review the Lock Out Tag Out authorized user list. Is there a copy of the knowledge test on file for each authorized associate? If no, list missing names or other discrepancies.

  Yes

  No

  N/A

• Has the Lock Out Tag Out annual review been conducted for all authorized employees?<br>

  Yes

  No

  N/A

• Review the training documentation for the powered industrial trucks. Are the file in good order, including an authorized user list?

  Yes

  No

  N/A

• Spot check the powered industrial training documentation for several users. Are the documents completely filled out, including the having the required signatures, initials, and valid dates of training?

  Yes

  No

  N/A

• Are SDS (Safety Data Sheets, formerly known as MSDS) on file for all chemicals used in the facility? If no, make note of any deficiencies.<br>

  Yes

  No

  N/A

• Are the SDS located in a binder and tabbed in order make it easier to quickly find a section?

  Yes

  No

  N/A

• Are there any additional concerns with the file or record keeping system?

  yes

  no

• During this audit were any items discovered that require corrective action?

  yes

  no

• Please enter corrective action recommendations, if applicable.

• Please enter any additional information or concerns regarding this audit.

• Signature of Person in Charge.

  Sign