ISS Light Industrial Client Site Safety Evaluation - TEMPLATE

• Company (Client) Name

• Client Location
  Address

• Nature of Business

• Phone Number

• W/C Code

• # of Client Employees

• # of Temp. Employees

• Conducted on

  Date

• Prepared by

Department Identification

• Which Departments do/will Temporary Employees work?

• Official Job Description(s)

  Media

General Condition

• Are all areas of the facility clean and sanitary? (ex: dirty workstations, lack of overall cleaning/dusting)

  Yes

  No

  N/A

• Is the work area free of spills and/or standing liquid?

  Yes

  No

  N/A

• Is the facility well lit in all areas?

  Yes

  No

  N/A

• Is the facility noisy to the point it is difficult to hold a conversation at a normal volume?

  Yes

  No

  N/A

• Are materials in the facility organized? (ex: boxes stacked neatly, pallets stacked together and organized, etc.)

  Yes

  No

  N/A

• Are the associates going to be exposed to the outside elements? (if yes, please explain)<br>

  Yes

  No

  N/A

• Are there any broken or damaged pallets being used?<br>

  Yes

  No

  N/A

• Walkways/Stairways

• Are any changes in elevation marked so that they can be easily identified?

  Yes

  No

  N/A

• Are there signs notating which direction the flow of foot traffic should go in?

  Yes

  No

  N/A

• Are there any trip hazards visible? (ex: cords, wires, debris, trash, etc….)

  Yes

  No

  N/A

• Are the walkways arranged such that foot traffic does not travel in hazardous areas? (ex: near rotating machinery, construction)

  Yes

  No

  N/A

• Do all stairways have stair/handrails?

  Yes

  No

  N/A

• Do all stairs have non-slip surfaces?

  Yes

  No

  N/A

• Are ladders and/or stepstools being used in the facility? (if yes, please describe their function)

  Yes

  No

  N/A

Administrative

• Does the client have a written safety program implemented for the purpose of injury prevention?

  Yes

  No

  N/A

• Does the client have an emergency evacuation plan to include severe weather provisions and evacuation map (including assembly areas)?

  Yes

  No

  N/A

• Does the client have a back injury prevention program?

  Yes

  No

  N/A

• Does the client have a program detailing bodily motion that is safe and unsafe?

  Yes

  No

  N/A

PIT Safety

• Will our associates be expected to drive PIT equipment?

  Yes

  No

  N/A

• Does the client have a certification/licensing program the associates will go through?

  Yes

  No

  N/A

• Are all PIT driving lanes clearly marked?

  Yes

  No

  N/A

• Do the PIT vehicles you observed seem to be in good working condition?

  Yes

  No

  N/A

• Are the PIT drivers operating the vehicles in a safe manner?

  Yes

  No

  N/A

Job Functions

• Are the associates taught safe and unsafe behaviors and bodily motion techniques?

  Yes

  No

  N/A

• Are associates rotated to different positions?

  Yes

  No

  N/A

• Are all tools and equipment at the employee workstations in good repair?

  Yes

  No

  N/A

Personal Protective Equipment (PPE)

• Will our associates be trained on what PPE is required for their workstation?

  Yes

  No

  N/A

• Will the proper PPE be provided for the associates by the client?

  Yes

  No

  N/A

• Are current employees wearing the proper PPE and wearing it correctly?

  Yes

  No

  N/A

Parking Lot

• Are there designated pedestrian walkways?

  Yes

  No

  N/A

• Are traffic signs (speed limit, crosswalk, stop) posted?

  Yes

  No

  N/A

• Is the parking lot well lit?

  Yes

  No

  N/A

• Is the parking lot monitored by video?

  Yes

  No

  N/A

• Overall, is the parking lot in good repair and condition?

  Yes

  No

  N/A

• Are there directions signs/arrows to designate the flow of traffic?

  Yes

  No

  N/A

Accident Investigation/Claims Management

• Will the client provide access for our representative to conduct a joint incident investigation with the client should an Integrity associate become injured?

  Yes

  No

  N/A

• Will the client be willing and able to accommodate associates with restrictions as a result of a work related incident?

  Yes

  No

  N/A

• Describe the client’s policy/procedure for reporting and investigating safety incidents, including steps taken to prevent further or repeat injuries:

• Additional comments/concerns that have not been addressed above: