Job Site Evaluation Report

• Customer Name:

• Location
  Address

• Person Interviewed

• Conducted on

  Date

• Prepared by

• Customer Name:

• Person Interviewed:

• Phone:

• Fax:

• Nature of Operations

• What type of work will workers be doing?

• What W.C. code will our workers be working under?

• Number of employees at site:

• Number of TrueBlue workers at site:

• Do you have a written safety program?

  Yes

  No

  N/A

• Do you have a written Hazzard Communication Program?

  Yes

  No

  N/A

• Do you have a program to identify and correct workplace hazards?

  Yes

  No

  N/A

• Do you have an Accident Investigation Program

  Yes

  No

  N/A

• Is OSHA and other required safety information posted?

  Yes

  No

  N/A

• Is emergency transportation available for injured employees

  Yes

  No

  N/A

• Will TrueBlue workers receive safety training/orientation and site/task Specific PPE training at the site, including emergency procedures, prior to starting work?

  Yes

  No

  N/A

• Are TrueBlue workers trained on new task assignments prior to beginning work?

  Yes

  No

  N/A

• Will documentation of training be provided to TrueBlue?

  Yes

  No

  N/A

• Will TrueBlue workers be required to comply with customer safety program rules?

  Yes

  No

  N/A

• Are machine guards in place?

  Yes

  No

  N/A

• Are customer's employees using required PPE?

  Yes

  No

  N/A

• Are power tools in safe condition?

  Yes

  No

  N/A

• Are electrical cords and equipment in safe condition?

  Yes

  No

  N/A

• Is site free of excessive noise?

  Yes

  No

  N/A

• Are proper lifting techniques being used?

  Yes

  No

  N/A

• Are trenches free of water and stored properly?

  Yes

  No

  N/A

• Are hazardous materials handled and stored properly?

  Yes

  No

  N/A

• Is fall protection being used (handrails, PPE ect.)?

  Yes

  No

  N/A

• Are there locations for TrueBlue employees to take their brake in the shade or other cool areas?

  Yes

  No

  N/A

• Is there plenty of portable water available for TrueBlue workers to stay hydrated?

  Yes

  No

  N/A

• Will you allow TrueBlue to conduct site investigation of accidents resulting in injury to our workers?

  Yes

  No

  N/A

PPE Required for TrueBlue workers on this site:

• Safety glasses /goggles :

  Yes

  No

  N/A

• Steel toe boots:

  Yes

  No

  N/A

• Slip resistant shoes:

  Yes

  No

  N/A

• Dusk mask/ respirators:

  Yes

  No

  N/A

• Safety vest:

  Yes

  No

  N/A

• Hearing protection:

  Yes

  No

  N/A

• Gloves:

  Yes

  No

  N/A

• Hard hats:

  Yes

  No

  N/A

• Special PPE to be provided by customer

  Yes

  No

  N/A

• Expain:

• If the answer to any of the questions is NO, explain the corrective action being taken prior to allowing workers to begin work.

• Are your observations consistent with customer's responses?

  Yes

  No

• Expain:

• Overall evaluation:

• Next Site Evaluation Visit Date:

  Date

• Evaluation Conducted by:

  Sign

• Select date

  Date

• Site Contact Signature:

  Sign

• Select date

  Date