• Company (Client) Name

  • Client Location
  • Nature of Business

  • Phone Number

  • W/C Code

  • # of Client Employees

  • # of Temp. Employees

  • Conducted on

  • Prepared by

Department Identification

  • Which Departments do/will Temporary Employees work?

  • Official Job Description(s)

General Condition

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

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

  • Is the facility well lit in all areas?

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

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

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

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

  • Walkways/Stairways

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

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

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

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

  • Do all stairways have stair/handrails?

  • Do all stairs have non-slip surfaces?

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


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

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

  • Does the client have a back injury prevention program?

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

PIT Safety

  • Will our associates be expected to drive PIT equipment?

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

  • Are all PIT driving lanes clearly marked?

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

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

Job Functions

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

  • Are associates rotated to different positions?

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

Personal Protective Equipment (PPE)

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

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

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

Parking Lot

  • Are there designated pedestrian walkways?

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

  • Is the parking lot well lit?

  • Is the parking lot monitored by video?

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

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

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?

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

  • 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:

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.