Information

  • Site conducted

  • Conducted on

  • Audit Title

  • Client Name

  • Client Website

  • Client Address
  • Personnel

  • Prepared by

  • Completed On

Company Information

Company Information

  • Years Been in Business

  • Total Number of In House Staff Employees

  • Total Number of Onsite Locations

  • Total Number of Onsite (Supervisor) Employees

  • Total Number of Active Temporary Employees

  • Previous Year's Total Revenue

  • Previous Years Total Hours

  • Estimate Revenue This Year

  • Estimate Total Hours This Year

Industry Specialty Type(s)

  • Agriculture

  • Cotton

  • Job Title(s) Serviced

  • Dairy

  • Job Title(s) Serviced

  • Coffee

  • Job Title(s) Serviced

  • Corn, Grain &/or Wheat

  • Job Title(s) Serviced

  • Fruits & Vegetables

  • Job Title(s) Serviced

  • Livestock

  • Job Title(s) Serviced

  • Nuts & Beans

  • Job Title(s) Serviced

  • Sugar

  • Job Title(s) Serviced

  • Tobacco

  • Job Title(s) Serviced

  • Wool

  • Job Title(s) Serviced

  • Assembly Operation

  • Job Title(s)?

  • Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.

  • Type(s) of Assembly Warehouse Work Environment(s)?

  • Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.

  • Aviation

  • Type(s) of Aviation Operations?

  • Type(s) of Job Title(s)?

  • Type(s) of Environment(s)?

  • Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.

  • Clerical

  • Type(s) of Job Title(s)?

  • Construction Industry?

  • Commercial Construction

  • Type(s) of Construction Project?

  • Type(s) of Work Environment?

  • Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.

  • Type(s) of Job Title(s)?

  • Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.

  • Residential Construction

  • Type(s) of Construction Project?

  • Type(s) of Work Environment?

  • Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.

  • Type(s) of Job Title(s)?

  • Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.

  • Crane Operation

  • Type of Crane(s)?

  • Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.

  • Education

  • Education Level

  • Type(s) of Job Title(s)?

  • Emergency Services

  • Type(s) of Emergency Service?

  • Type(s) of Job Title(s)?

  • Type(s) of Environment(s)?

  • Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.

  • Environmental Clean Up & Response

  • Job Title(s)?

  • Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc. (include Disaster Site Recovery Certification Procedures)

  • Firearm, Ammunition & Explosives Manufacturing

  • Type(s) of Job Title(s)?

  • Type(s) of Environment(s)?

  • Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.

  • Fire/Flood Clean Up & Response

  • Job Title(s)?

  • Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc. (include Disaster Site Recovery Certification Procedures)

  • Forestry & Logging Industry?

  • Job Titles?

  • Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.

  • Foundry Operation

  • Work Environment(s)?

  • Type(s) of Metal(s)?

  • Job Title(s)?

  • Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.

  • Hospitality Industry

  • Job Title(s)?

  • Healthcare

  • Job Titles?

  • Iron/Steel Erection

  • Job Title(s)?

  • Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.

  • Law Enforcement

  • Job Title?

  • Machine Press Manufacturing?

  • Type of Press Mechanism(s)?

  • Type(s) of Machine(s)?

  • Type of Molding Environment(s)?

  • Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.

  • Maritime

  • Job Title?

  • Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.

  • Mass Transit

  • Job Title?

  • Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.

  • Mining

  • Type of Mining?

  • Type of Minerals Mined?

  • Job Titles

  • Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.

  • Molding Manufacturing?

  • Type of Press Mechanism(s)?

  • Type(s) of Machine(s)?

  • Type of Molding Environment(s)?

  • Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.

  • Oil/Gas/Off Shore Operations

  • Type of Operation

  • Job Title

  • Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.

  • Restaurant Industry

  • Job Title(s)?

  • Skilled Labor

  • Job Title(s)?

  • Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.

  • Utilities?

  • Type(s) of Utility(s)?

  • Type(s) of Work Environment?

  • Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.

  • Warehouse Operation

  • Type(s) of Warehouse Work Environment(s)?

  • Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.

  • Job Title(s)?

  • Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.

  • Waste, Recycle &/or Refuse Operation

  • Type(s) of Waste, Recycle & Refuse Operation?

  • Job Title

Branch Locations

  • Multiple Branch Locations

  • Total Number of Branch Locations

  • Branch Office #1 Name

  • Branch Office #1 Manager Name

  • Branch Office #1 Address
  • Branch Office #2?

  • Branch Office #2 Name

  • Branch Office #2 Manager Name

  • Branch Office #2 Address
  • Branch Office #3?

  • Branch Office #3 Name

  • Branch Office #3 Manager Name

  • Branch Office #3 Address
  • Branch Office #4?

  • Branch Office #4 Name

  • Branch Office #4 Manager Name

  • Branch Office #4 Address
  • Branch Office #5

  • Branch Office #5 Name

  • Branch Office #5 Manager Name

  • Branch Office #5 Address
  • Branch Office #6?

  • Branch Office #6 Name

  • Branch Office #6 Manager Name

  • Branch Office #6 Address
  • Branch Office #7?

  • Branch Office #7 Name

  • Branch Office #7 Manager Name

  • Branch Office #7 Address
  • Branch Office #8?

  • Branch Office #8 Name

  • Branch Office #8 Manager Name

  • Branch Office #8 Address
  • Branch Office #9?

  • Branch Office #9 Name

  • Branch Office #9 Manager Name

  • Branch Office #9 Address
  • Branch Office #10?

  • Branch Office #10 Name

  • Branch Office #10 Manager Name

  • Branch Office #10 Address
  • Branch Office #11?

  • Branch Office #11 Name

  • Branch Office #11 Manager Name

  • Branch Office #11 Address
  • Branch Office #12?

  • Branch Office #12 Name

  • Branch Office #12 Manager Name

  • Branch Office #12 Address
  • Branch Office #13?

  • Branch Office #13 Name

  • Branch Office #13 Manager Name

  • Branch Office #13 Address
  • Branch Office #14?

  • Branch Office #15?

  • Branch Office #15 Name

  • Branch Office #15 Manager Name

  • Branch Office #15 Address
  • Branch Office #14 Name

  • Branch Office #14 Manager Name

  • Branch Office #14 Address

Company Safety

  • Dedicated Safety Professional

  • Name & Title of Safety Professional

  • Telephone Number

  • Email Address

  • Years of Experience

  • Safety Designations

  • Document & Maintain Loss Documentation for Analysis?

  • How Often Are All Incidents, Accidents, Near Miss &/or Med Refusal Occurrences Data Analyzed?

  • Does Client Have an Injury & Illness Prevention Program?

  • Injury & Illness Prevention Program in Place

  • Injury & Illness Prevention Program Reviewed?

  • How Often?

  • Does Client Perform Safety Meetings?

  • How Often With Branch Staff?

  • How Often with EE's?

  • Safety Meetings Documented Verbally?

  • Safety Meeting Documented in Writing and Maintained in EE's file? (Signed Acknowledgement form by EE)

  • In House Safety Committee Established?

  • How Often Does Safety Committee Meet?

  • Member of Host Employers Safety Committee?

  • How Often Does Safety Committee Meet?

  • Safety Meeting Documentation Compliance Audit Performed?

  • How Often?

Drug Free Work Place Program

  • Do You Have a "Written" Drug Free Work Place Program?

  • Is Your Drug Free Work Place Program in Force?

  • Pre-Employment Drug Screen Program?

  • Post Accident Drug Screen Program?

  • Random Drug Screen Program?

  • Reasonable Suspicion Drug Screen Program?

  • Return to Work Drug Screen Program (After One Week Absence)

New Client Screening

  • Assessment of Job Duties?

  • Client Injury & Illness Prevention Program Review?

  • Client OSHA Logs Review?

  • Confirmation of Dedicated Safety Professional?

  • Confirmation of a Safety Committee?

  • D & B (Dun & Bradstreet) Check?

  • E-Mod Check?

  • Face to Face Visit with Client?

  • FMCSA SMS Database Check (DOT & Vehicle Maintenance Compliance)?

  • OSHA Establishment Check?

  • Site Visit to Determine Exposures & Hazards?

New Employee Screening

  • Application?

  • Behavioral Assessment?

  • Criminal Background Screen?

  • Current CDL License?

  • Current DOT Medical Credentials?

  • Health Screening (TB, HEP Series, etc.)?

  • I-9 Verification?

  • In Person Interview?

  • Pre-Employment Drug Screen?

  • MVR Check?

  • Personal Reference Screen?

  • Reliable Transportation?

  • Technical Skills Assessment?

  • Valid Skilled Labor Licensing?

  • W/C Claim History Screen?

  • Work Experience Verification?

New Employee Safety Training

  • Does Client Perform New Hire Safety Orientation Training?

  • Do All Employees Execute an Acknowledgement Form Acknowledging & Understanding Training Received?

  • Ariel Lifts Training?

  • Minimum & Maximum Work Height? Outline Specific Job Title, Duties, Environment and Types of Fall Protection Required. Host Employer Name and Address. (OSHA Fall Protection Trigger 10 Feet for Scaffolding Under Construction Industry; State OSHA triggers may be more stringent)

  • Does Client Verify if Host Employer has a Fall Prevention Program In place (Site by Site Specific)?

  • CDL Operation Training?

  • Outline Specific Job Title, Duties and Types of Vehicles, Type of Freight, Environments & Host Employer Name and Address.

  • Outline Specific Initial Screening & Testing (Including Medical), DOT Compliance, Documentation, Maintenance of Documentation and Follow Up Procedures

  • Define Client's Specific Screening & Training Obligations

  • Define Host Employer's Screening & Training Obligations

  • Client Specific Safety Orientation Training Video?

  • Confined Space (Including Permit Required) Training?

  • Outline Specific Job Title, Duties and Types of Confined Space Work, Job Sites, Environments & Host Employer Name and Address.

  • Outline Specific Initial Screening & Testing(Including Medical & PPE Fitting), OSHA Certification, Documentation, Maintenance of Documentation and Follow Up Procedures

  • Does Client have a Confined Space (including Permit Required) Program in Place?

  • Does Host Employer Have a Written Confined Space (including Permit Required) Program in Place?

  • Define Client's Specific Screening & Training Obligations

  • Define Host Employer's Specific Screening & Training Obligations

  • Crane Operation?

  • Outline Specific Job Title, Duties and Types of Cranes, Job Sites, Environments & Host Employer Name and Address.

  • Outline Specific Initial Screening & Testing, OSHA Certification, Documentation, Maintenance of Documentation and Follow Up Procedures

  • Define Client's Specific Screening & Training Obligations

  • Define Host Employer's Specific Screening & Training Obligations

  • Defensive Driving Training?

  • Outline Specific Job Title, Duties and Types of Vehicles, Type of Freight, Environments & Host Employer Name and Address.

  • Outline Specific Initial Screening & Testing, DOT Certification, Documentation, Maintenance of Documentation and Follow Up Procedures

  • Define Client's Specific Screening & Training Obligations

  • Define Host Employer's Specific Screening & Training Obligations

  • Execution of General Safety Rule Acknowledgement Form?

  • Fall Protection Training?

  • Type of Fall Protection Required?

  • Minimum & Maximum Work Height? Outline Specific Job Title, Duties, Environment and Types of Fall Protection Required. Host Employer Name and Address. (OSHA Fall Protection Trigger for General Industry 4 feet and 6 Feet for Construction Industry; State OSHA triggers may be more stringent)

  • Define Client's Specific Screening & Training Obligations

  • Define Host Employer's Specific Screening & Training Obligations

  • Forklift Training?

  • Outline Specific Job Title, Duties and Types of Powered Industrial Vehicles, Type of Material Handled, Environments & Host Employer Name and Address.

  • Outline Specific Initial Screening & Testing, OSHA Certification, Documentation, Maintenance of Documentation and Follow Up Procedures.

  • Define Client's Specific Screening & Training Obligations

  • Define Host Employer's Specific Screening & Training Obligations

  • General Safety Orientation Video?

  • General Bloodborne Pathogen Training?<br>

  • Outline Specific Job Title, Duties and Potential Type of Exposures. Define Work Environments & Host Employer Name and Address.

  • Outline Specific Initial Screening & Testing(Including Medical and PPE Fitting), Documentation, Maintenance of Documentation and Follow Up Procedures

  • Does Client Have a Written Bloodborne Pathogen Program In Place?

  • Does Host Employer Have a Written Bloodborne Pathogen Program in Place?

  • Define Client's Specific Screening & Training Obligations

  • Define Host Employer's Specific Screening & Training Obligations

  • Bloodborne Pathogen Program in Place?

  • GHS HAZCOM Training?

  • Does Client Have a Written GHS HAZCOM Program in Place?

  • Does Host Employer Have a Written GHS HAZCOM Program in Place?

  • Define Client's Specific Screening & Training Obligations

  • Define Host Employer's Specific Screening & Training Obligations

  • Hand Tools Training?

  • Outline Specific Job Title, Duties, Types of Tools required to operate & Host Employer Name and Address.

  • Define Client's Specific Screening & Training Obligations

  • Define Host Employer's Specific Screening & Training Obligations

  • HAZMAT Training?

  • Outline Specific Job Title, Duties, Required Types of PPE, Equipment, Types of Vehicles, Type of Freight, All Types of Hazardous Material, Environments & Host Employer Name and Address.

  • Outline Specific Initial Screening & Testing(Including Medical and PPE Fitting), OSHA Certification, Documentation, Maintenance of Documentation and Follow Up Procedures

  • Does Client Have a Written HAZMAT Program in Place?

  • Does Host Employer have a Written HAZMAT Program in Place?

  • Define Client's Specific Screening & Training Obligations

  • Define Host Employer's Specific Screening & Training Obligations

  • HAZWOPER Training?

  • Outline Specific Initial Screening & Testing(Including Medical and PPE Fitting), OSHA Certification, Documentation, Maintenance of Documentation and Follow Up Procedures

  • Outline Specific Job Title, Duties, Required Types of PPE, Equipment, Types of Vehicles, Type of Freight, All Types of Hazardous Waste(s), Environments & Host Employer Name and Address.

  • Does Client Have a Written HAZWOPER Program in Place?

  • Does Host Employer have a Written HAZWOPER Program in Place?

  • Define Client's Specific Screening & Training Obligations

  • Define Host Employer's Specific Screening & Training Obligations

  • Hearing Conservation Training?

  • Outline Specific Job Title, Duties, Required Types of PPE, Environments & Host Employer Name and Address.

  • Outline Specific Initial Screening & Testing(Including Medical), Documentation, Maintenance of Documentation and Follow Up Procedures

  • Does Client Have Written Hearing Conservation Program in Place?

  • Does Client Arrange To Have Annual Audiograms Performed, At No Cost To Their Affected Employees?

  • Does Host Employer include Client's Affected Employee's In Its Testing Program?

  • Define Client's Specific Screening & Training Obligations

  • Define Host Employer's Specific Screening & Training Obligations

  • Lock Out/Tag Out Training?

  • Outline Specific Job Title, Duties, Required Types of PPE, Equipment, Environments & Host Employer Name and Address.

  • Does Client Have a Written Lock Out/Tag Out Program in Place?

  • Does Host Employer Have a Written Lock Out/Tag Out Program in Place?

  • Define Client's Specific Training Obligations

  • Define Host Employer's Specific Training Obligations

  • Machine Guarding Training?

  • Needle Stick/SHARPS Training?

  • Outline Specific Job Title, Duties and Potential Type of Exposures. Define Work Environments & Host Employer Name and Address.

  • Outline Specific Initial Screening & Testing(Including Medical and PPE Fitting), Documentation, Maintenance of Documentation and Follow Up Procedures

  • Does Client Have a Written Needle Stick/SHARPS Program?

  • Does Host Employer Have a Written Needle Stick/SHARPS Program?

  • Define Client's Specific Screening & Training Obligations

  • Define Host Employer's Specific Screening & Training Obligations

  • Policy and Procedures Check List Acknowledgement Form?

  • Motorized Equipment Operation Training?

  • Outline Specific Job Title, Duties and Types of Motorized Equipment, Type of Material Handled, Environments & Host Employer Name and Address.

  • Outline Specific Initial Screening & Testing, OSHA Certification, Documentation, Maintenance of Documentation and Follow Up Procedures.

  • Define Client's Specific Screening & Training Obligations

  • Define Host Employer's Specific Screening & Training Obligations

  • PPE Compliance Training?

  • Respiratory Protection Training?

  • Outline Specific Job Title, Duties and Types of Respirator Equipment, Type of Material Handled, Environments & Host Employer Name and Address.

  • Outline Specific Initial Screening & Testing(Including Medical & PPE Fitting), OSHA Certification, Documentation, Maintenance of Documentation and Follow Up Procedures

  • Does Client Have a Written Respiratory Protection Program In Place?

  • Does Host Employer Have a Written Respiratory Protection Program In Place?

  • Define Client's Specific Screening & Training Obligations

  • Define Host Employers Specific Screening & Training Obligations

  • Review Of Job Duties?

  • Review of Job Duties Verbal

  • Review of Job Duties in Writing (EE Executes Acknowledgment of Review)

  • Scaffolding Training?

  • Does Client Verify if Host Employer has a Fall Prevention Program In place (Site by Site Specific)?

  • Does Client Verify Host Employer has a Qualified Person Inspect Scaffold at the Start of each Shift?

OSHA Logs & Safety Compliance

  • Are OSHA 300 Logs Kept and Maintained?

  • Are OSHA 300a Summary Forms Posted at Each Branch Locations from 02/01 - 04/30?

  • Are OSHA 301 Forms Kept and Maintained?

  • Does Client Have a Progressive Disciplinary Program in Place?

  • New Equipment or Process Training (Documented)?

  • Retrain &/or Re-Certification Program in Place for all reported adverse events (including unsafe operation, near miss, &/or Med Refusal Occurrences)?

  • Safety & Compliance Checks (Documented)?

  • How Often?

  • Safety Incentive Program?

OSHA Establishment Inspection Inquiry

  • OSHA Visit History-Current Year?

  • Total OSHA Visit(s)-Current Year

  • Total Number of Visits Due to A Catastrophe(s) &/or Fatality(s)?

  • Provide Details of Catastrophe(s) &/or Fatality(s) that Prompted Inspection(s)

  • Total Number of Visit(s) as a Result of a Complaint(s)?

  • Provide Details and Results of Inspection(s) Prompted by Complaint(s)

  • Total Number of Visits as a Result of a Follow-Up Inspection(s)?

  • Provide Details and Results of Inspection(s) Prompted by Follow-Up Inspection(s), Including Details To Initial Inspection Visit(s)

  • Total Number of Visits Due to Imminent Danger(s)

  • Provide Details of Imminent Danger(s) that Prompted Imminent Danger Visit

  • Total Number of Visits as a Result of Programmed Inspection(s)?

  • Provide Details and Results of Programmed Inspection(s)

  • Total Number of Visits as a Result of a Referral(s)?

  • Provide Details and Results of Inspection(s) Prompted by Referral(s)

  • Total Number of Violation(s)?

  • Total Number of Repeat Violations?

  • Provide Details on Standard(s) Cited and Abatements

  • Total Dollar Amount of Repeat Violation(s)?

  • Total Number of Serious Violations?

  • Provide Details on Standard(s) Cited and Abatements

  • Total Dollar Amount of Serious Violation(s)?

  • Total Number of Willful Violation(s)?

  • Total Dollar Amount of Willful Violation(s)

  • Provide Details on Standard(s) Cited and Abetements

  • OSHA Visit History-2013?

  • Total OSHA Visit(s)-2013

  • Total Number of Visits Due to A Catastrophe(s) &/or Fatality(s)?

  • Provide Details of Catastrophe(s) &/or Fatality(s) that Prompted Inspection(s)

  • Total Number of Visit(s) as a Result of a Complaint(s)?

  • Provide Details and Results of Inspection(s) Prompted by Complaint(s)

  • Total Number of Visits as a Result of a Follow-Up Inspection(s)?

  • Provide Details and Results of Inspection(s) Prompted by Follow-Up Inspection(s), Including Details To Initial Inspection Visit(s)

  • Total Number of Visits Due to Imminent Danger(s)

  • Provide Details of Imminent Danger(s) that Prompted Imminent Danger Visit

  • Total Number of Visits as a Result of Programmed Inspection(s)?

  • Provide Details and Results of Programmed Inspection(s)

  • Total Number of Visits as a Result of a Referral(s)?

  • Provide Details and Results of Inspection(s) Prompted by Referral(s)

  • Total Number of Violation(s)?

  • Total Number of Repeat Violations?

  • Provide Details on Standard(s) Cited and Abatements

  • Total Dollar Amount of Repeat Violation(s)?

  • Total Number of Serious Violations?

  • Provide Details on Standard(s) Cited and Abatements

  • Total Dollar Amount of Serious Violation(s)?

  • Total Number of Willful Violation(s)?

  • Total Dollar Amount of Willful Violation(s)

  • Provide Details on Standard(s) Cited and Abetements

  • OSHA Visit History-2012?

  • Total OSHA Visit(s)-2012

  • Total Number of Visits Due to A Catastrophe(s) &/or Fatality(s)?

  • Provide Details of Catastrophe(s) &/or Fatality(s) that Prompted Inspection(s)

  • Total Number of Visit(s) as a Result of a Complaint(s)?

  • Provide Details and Results of Inspection(s) Prompted by Complaint(s)

  • Total Number of Visits as a Result of a Follow-Up Inspection(s)?

  • Provide Details and Results of Inspection(s) Prompted by Follow-Up Inspection(s), Including Details To Initial Inspection Visit(s)

  • Total Number of Visits Due to Imminent Danger(s)

  • Provide Details of Imminent Danger(s) that Prompted Imminent Danger Visit

  • Total Number of Visits as a Result of Programmed Inspection(s)?

  • Provide Details and Results of Programmed Inspection(s)

  • Total Number of Visits as a Result of a Referral(s)?

  • Provide Details and Results of Inspection(s) Prompted by Referral(s)

  • Total Number of Violation(s)?

  • Total Number of Repeat Violations?

  • Provide Details on Standard(s) Cited and Abatements

  • Total Dollar Amount of Repeat Violation(s)?

  • Total Number of Serious Violations?

  • Provide Details on Standard(s) Cited and Abatements

  • Total Dollar Amount of Serious Violation(s)?

  • Total Number of Willful Violation(s)?

  • Total Dollar Amount of Willful Violation(s)

  • Provide Details on Standard(s) Cited and Abetements

  • OSHA Visit History-2011?

  • Total OSHA Visit(s)-2011

  • Total Number of Visits Due to A Catastrophe(s) &/or Fatality(s)?

  • Provide Details of Catastrophe(s) &/or Fatality(s) that Prompted Inspection(s)

  • Total Number of Visit(s) as a Result of a Complaint(s)?

  • Provide Details and Results of Inspection(s) Prompted by Complaint(s)

  • Total Number of Visits as a Result of a Follow-Up Inspection(s)?

  • Provide Details and Results of Inspection(s) Prompted by Follow-Up Inspection(s), Including Details To Initial Inspection Visit(s)

  • Total Number of Visits Due to Imminent Danger(s)

  • Provide Details of Imminent Danger(s) that Prompted Imminent Danger Visit

  • Total Number of Visits as a Result of Programmed Inspection(s)?

  • Provide Details and Results of Programmed Inspection(s)

  • Total Number of Visits as a Result of a Referral(s)?

  • Provide Details and Results of Inspection(s) Prompted by Referral(s)

  • Total Number of Violation(s)?

  • Total Number of Repeat Violations?

  • Provide Details on Standard(s) Cited and Abatements

  • Total Dollar Amount of Repeat Violation(s)?

  • Total Number of Serious Violations?

  • Provide Details on Standard(s) Cited and Abatements

  • Total Dollar Amount of Serious Violation(s)?

  • Total Number of Willful Violation(s)?

  • Total Dollar Amount of Willful Violation(s)

  • Provide Details on Standard(s) Cited and Abetements

Accident Investigation & Reporting

  • All Reported Incidents Reported to Carrier or TPA within 24 hours (Including Med-Refusals)

  • Are Employees Required to Notify Both Client & Host Employer immediately of all work related events, regardless of severity?

  • Provide Details on Who and When Employees are Required to Report Work Related Events?

  • Client Completes an Accident/Incident Investigation Form(Possibly Coordinated with Host Employer)?

  • Client Conducts Onsite Accident/Incident Investigation Immediately?

  • Provide Details on Who Conducts Onsite Accident/Incident Investigation and When?

  • Currently Has a Preferred Medical Provider Vendor Pool?

  • Is an ER the Preferred Health Care Provider for all Injuries and Drug Screens?

  • Is a Non Urgent (Occupational) Care Facility the Preferred Health Care Provider for all Non-Life-Threatening or Non Immediate Emergency Injuries and Drug Screens?

  • Urgent Care Facility the Preferred Health Care Provider for all Non-Life-Threatening or Non Immediate Emergency Injuries and Drug Screens?

  • Medical Provider Protocols Established with Each Provider?

  • Medical Care Provider forwards Medical & Post Accident Drug Screen Documentation to Client immediately after each visit?

  • Currently Pay Any Injury, Accident or Post Accident/Incident Drug Screen Expenses In House?

  • Detail What Expenses are Currently Paid in House

  • Currently Pay/Handle Any Reported Incidents/Accidents/Injuries In House?

  • Detail What Incidents/Accidents/Injuries are Currently Handled in House

  • Employee Required to Complete and Execute a Statement of Refusal of Medical Treatment, if Medical Treatment is Declined at the Time of Report?

  • Employee Required to Complete an Employee Statement of Injury/Incident/Near Miss?

  • Employee Required to Forward All Medical Documentation Immediately After Each Doctors Visit?

  • Employee Required to Contact Branch Office Once a Week To Update Current Medical and Work Status?

  • For Non-Immediate Emergency Injuries; Client Transports Injured Worker to Health Care Provider

  • For Non-Immediate Emergency Injuries; Employee Required to Transport Themselves to Health Care Provider

  • For Non-Immediate Emergency Injuries; Host Employer Transports Injured Worker to Health Care Provider

  • Post Accident/Incident Drug Screen Required (including Med Refusal, Near Miss and Unsafe Operation Occurrences)

  • Provide Light Duty Accommodations to Injured Workers?

  • Light Duty Accommodations?

  • Official Bona Fide Offer of Employment Letter Provided to Employee for Acceptance & Execution, by Verifiable Means? (Copy of Work Status Report Must also be attached and sent Certified Mail, if being mailed)

  • Employee Paid Same Wages and Similar Hours?

Claim History

  • Loss Runs Provided for Review?

  • 2013 Loss Runs Provided

  • Total Number of Claims for Policy Year 2013

  • Total Incurred for Policy Year 2013

  • Explain Frequency and Total Incurred for Policy Year 2013

  • Details of Circumstances regarding Highest Total Incurred Claims

  • 2012 Loss Runs Provided

  • Total Number of Claims for Policy Year 2013

  • Total Incurred for Policy Year 2013

  • Explain Frequency and Total Incurred for Policy Year 2013

  • Details of Circumstances regarding Highest Total Incurred Claims

  • 2011 Loss Runs Provided

  • Total Number of Claims for Policy Year 2013

  • Total Incurred for Policy Year 2013

  • Explain Frequency and Total Incurred for Policy Year 2013

  • Details of Circumstances regarding Highest Total Incurred Claims

  • 2010 Loss Runs Provided

  • Total Number of Claims for Policy Year 2013

  • Total Incurred for Policy Year 2013

  • Explain Frequency and Total Incurred for Policy Year 2013

  • Details of Circumstances regarding Highest Total Incurred Claims

  • 2013 Loss Runs Provided

  • Total Number of Claims for Policy Year 2013

  • Total Incurred for Policy Year 2013

  • Explain Frequency and Total Incurred for Policy Year 2013

Non CDL/DOT Motor Vehicle Operation

  • Employees Required to Operator Motor Vehicles As a Condition of Employment

  • Job Title(s)?

  • Driver(s) Screened?

  • Initial MVR Check?

  • Follow Up MVR Checks?

  • Defensive Driving Certification Course?

  • Vehicle Ownership?

  • Vehicle Maintained By?

  • Type of Vehicles?

  • Daily Pre Trip Vehicle Inspections Completed?<br>

  • Daily Pre Trip Vehicle Inspections Documented and Maintained on File?

  • Daily Post Trip Vehicle Inspections Completed?<br>

  • Daily Post Trip Vehicle Inspections Documented and Maintained on File?

  • Group Employee Transport?

  • Dedicated Route?

  • Total Number of Employees Transported?

  • CDL May be Required as well as State or Federal DOT Jurisdication

  • Total Distance (Miles) Driven Per Day

  • Explain driver demands.

  • Local Route?<br>

  • Dedicated Route?

  • Overnight Travel?

  • Duration of Job Assignment and Job Duties

  • Crossing State Lines

  • State Lines Crossed?

  • Total Estimated Miles to Drive (Current Year)

  • Total Miles Driven (Previous Year)

  • No Touch Product/Freight Delivery?<br>

  • Transporting HAZMAT, Hazardous Waste, Bio-Hazards, Alcohol, etc.?

  • Type of HAZMAT

CDL/DOT Motor Vehicle Operation

  • Are Employees Required to Operate any Motor Vehicles Requiring CDL Designations or Endorsements?

  • Initial MVR Check?

  • Follow Up MVR Checks?

  • How Often?

  • Defensive Driving Course Completion Certification?

  • List All Required CDL Designations

  • CDL Drivers Require Special Endorsements?

  • H - HAZMAT Endorsement?

  • Provide Specific List of Hazardous Material, Type of Vehicle(s), Specific Job Duties, Distance Traveled, etc.

  • N - Tanker

  • undefined

  • P - Passenger Vehicle Endorsement?

  • Provide Maximum Number of Passengers to Transport, Type of Vehicle(s), Local, Regional or Cross Country Dedicated Routes, Specific Job Duties, Distance Traveled, etc.

  • S - School Bus Endorsement?

  • Provide Maximum Number of Passenger to Transport, Type of Vehicle(s), Specific Job Duties, Distance Traveled, etc. School District Servicing.

  • T - Double or Triple Trailers Endorsement?

  • Provide Specific List of Freight, Material, Type of Vehicle(s), Specific Job Duties, Distance Traveled, etc.

  • X - Combination of tank vehicle and hazardous materials endorsements?<br>

  • Provide Specific List of Product Transported, Type of Vehicle(s), Specific Job Duties, Distance Traveled, etc.

  • CDL Vehicle Ownership?

  • CDL Vehicle Maintained By?

  • Daily Pre-Trip Vehicle Inspections Documented and Maintained on File?

  • Daily Post-Trip Vehicle Inspections Documented and Maintained on File?

  • USDOT# &/or MCDOT# Required?

  • Provide USDOT# &/or MCDOT#

  • Federal Motor Carrier Inspection History in Safety Measurement System Database(Current Year)?

  • Total Number of Inspections Current Year?

  • Total Number of Controlled Substance &/or Alcohol Related Inspection Violation(s) (Current Year)?

  • Explanation of Controlled Substance &/or Alcohol Related Inspection Violation(s) and Detail Any Corrective Measures Taken?

  • Total Number of Crash Indicators Violation(s) (Current Year)?

  • Crash Result in a Fatality?

  • Explanation of Crash Indicator Related Violation(s), Circumstances Regarding any Crash Resulting in a Fatality and Detail Any Corrective Measures Taken?

  • Total Number of Driver Fitness Related Inspection Violation(s) (Current Year)?

  • Explanation of Driver Fitness Related Inspection Violation(s) and Detail Any Corrective Measures Taken?

  • Total Number of HAZMAT (HM) Compliance Related Inspection Violation(s) (Current Year)?

  • Explanation of HAZMAT (HM) Related Inspection Violation(s), List of Hazardous Materials and Detail Any Corrective Measures Taken?

  • Total Number of Hours of Service Related Inspection Violation(s) (Current Year)?

  • Explanation of Hours of Service Related Inspection Violation(s) and Detail Any Corrective Measures Taken?

  • Total Number of Unsafe Driving Related Inspection Violation(s) (Current Year)?

  • Explanation of Unsafe Driving Related Inspection Violation(s) and Detail Any Corrective Measures Taken?

  • Total Number of Vehicle Maintenance Related Inspection Violation(s) (Current Year)?

  • Explanation of Vehicle Maintenance Related Inspection Violation(s) and Detail Any Corrective Measures Taken?

  • Federal Motor Carrier Inspection History in Safety Measurement System Database (Year 2013)?

  • Total Number of Inspections Year 2013?

  • Total Number of Controlled Substance &/or Alcohol Related Inspection Violation(s) Year 2013?

  • Explanation of Controlled Substance &/or Alcohol Related Inspection Violation(s) and Detail Any Corrective Measures Taken?

  • Total Number of Crash Indicators Violation(s) Year 2013?

  • Crash Result in a Fatality?

  • Explanation of Crash Indicator Related Violation(s), Circumstances Regarding any Crash Resulting in a Fatality and Detail Any Corrective Measures Taken?

  • Total Number of Driver Fitness Related Inspection Violation(s) Year 2013?

  • Explanation of Driver Fitness Related Inspection Violation(s) and Detail Any Corrective Measures Taken?

  • Total Number of HAZMAT (HM) Compliance Related Inspection Violation(s) Year 2013?

  • Explanation of HAZMAT (HM) Related Inspection Violation(s), List of Hazardous Materials and Detail Any Corrective Measures Taken?

  • Total Number of Hours of Service Related Inspection Violation(s) Year 2013?

  • Explanation of Hours of Service Related Inspection Violation(s) and Detail Any Corrective Measures Taken?

  • Total Number of Unsafe Driving Related Inspection Violation(s) Year 2013?

  • Explanation of Unsafe Driving Related Inspection Violation(s) and Detail Any Corrective Measures Taken?

  • Total Number of Vehicle Maintenance Related Inspection Violation(s) Year 2013?

  • Explanation of Vehicle Maintenance Related Inspection Violation(s) and Detail Any Corrective Measures Taken?

  • Federal Motor Carrier Inspection History in Safety Measurement System Database Year 2012?

  • Total Number of Inspections Year 2012?

  • Total Number of Controlled Substance &/or Alcohol Related Inspection Violation(s) Year 2012?

  • Explanation of Controlled Substance &/or Alcohol Related Inspection Violation(s) and Detail Any Corrective Measures Taken?

  • Total Number of Crash Indicators Violation(s) Year 2012?

  • Crash Result in a Fatality?

  • Explanation of Crash Indicator Related Violation(s), Circumstances Regarding any Crash Resulting in a Fatality and Detail Any Corrective Measures Taken?

  • Total Number of Driver Fitness Related Inspection Violation(s) Year 2012?

  • Explanation of Driver Fitness Related Inspection Violation(s) and Detail Any Corrective Measures Taken?

  • Total Number of HAZMAT (HM) Compliance Related Inspection Violation(s) Year 2012?

  • Explanation of HAZMAT (HM) Related Inspection Violation(s), List of Hazardous Materials and Detail Any Corrective Measures Taken?

  • Total Number of Hours of Service Related Inspection Violation(s) Year 2012?

  • Explanation of Hours of Service Related Inspection Violation(s) and Detail Any Corrective Measures Taken?

  • Total Number of Unsafe Driving Related Inspection Violation(s) Year 2012?

  • Explanation of Unsafe Driving Related Inspection Violation(s) and Detail Any Corrective Measures Taken?

  • Total Number of Vehicle Maintenance Related Inspection Violation(s) Year 2012?

  • Explanation of Vehicle Mainenance Related Inspection Violation(s) and Detail Any Corrective Measures Taken?

  • Interstate Driving (State to State)

  • Type of Commodity Transported?

  • Travel To & Through Which States?

  • Types of Vehicles?

  • Total Estimated Miles to Drive (Current Year)

  • Total Miles Driven (Previous Year)

  • Total Estimated Miles to Drive (Current Year)

  • Total Miles Driven (Previous Year)

  • Assist With Load & Unload?

  • Describe Driver Load and Unload Assist Requirements

  • Dedicated Local Route?

  • Provide Dedicated Route Details

  • No Touch Freight?

  • Intrastate Driving (State of Origination Only)

  • Type of Commodity Transported?

  • Travel To & Through Which States?

  • Types of Vehicles?

  • Total Estimated Miles to Drive (Current Year)

  • Total Miles Driven (Previous Year)

  • Total Estimated Miles to Drive (Current Year)

  • Total Miles Driven (Previous Year)

  • Assist With Load & Unload?

  • Describe Driver Load and Unload Assist Requirements

  • Dedicated Local Route?

  • Provide Dedicated Route Details

  • No Touch Freight?

Loss Prevention & Control Philosophy

  • Acceptable Risk for Vensure Employer Services?

  • Provide Detailed Explanation

  • Demonstrated an Eagerness to Learn and Implement Other Policy & Procedures?

  • Provide Detailed Explanation

  • Demonstrated Strong Safety First Company Philosophy?

  • Provide Detailed Explanation

  • Exhibited a Production/Sales First Philosophy?

  • Provide Detailed Explanation

  • Expressed a Commitment to Form a Partnership with Vensure Loss Control Team?

  • Provide Detailed Explanation

  • Immediately Objected to OSHA/DOT and/or Industry Standard Compliance Issues?

  • Provide Detailed Explanation

  • Receptive to Scheduling In Person Loss Control Visit Within 30 Days of Onboarding?

  • Provide Detailed Explanation

  • Seemed Disengaged from Loss Prevention & Loss Control Processes?

  • Provide Detailed Explanation

  • Relies on Host Employer to Perform All Loss Prevention & Loss Control Compliance Requirements?

  • Provide Detailed Explanation

  • Voiced Any Objections to Issues That May Not Be OSHA/DOT Compliant or Industry Standard?

  • Provide Detailed Explanation

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.