LARMA School Site Inspections

• Site conducted

  Select

• Location

• Conducted on

  Date

• Name of person who accompanied inspector

• Prepared by

Administration

• Have all previously reported defects been rectified?

  Yes

  No

  N/A

• Have accident records been reviewed to identify potential hazards?

  Yes

  No

• Does the facility have a Safety Committee?

  Yes

  No

  N/A

• How often does the committee meet?

  Select Weekly Bi Weekly Monthly Quarterly Semi-Annually Annually

  • Weekly
  • Bi Weekly
  • Monthly
  • Quarterly
  • Semi-Annually
  • Annually

• Does the facility have an Incident Investigation procedure?

  Yes

  No

  N/A

• EAP written and available to employees

  Yes

  No

  N/A

Policies and Procedures

• Written Fire Prevention Plan

  Yes

  No

  N/A

• Plan Administrator name

• Procedures to control accumulations of flammable and combustible waste?

  Yes

  No

  N/A

• Fire safety training provided to employees?

  Yes

  No

  N/A

• Emergency Evacuation routes and maps posted

  Yes

  No

  N/A

• Exits discharge directly to building exterior?

  Yes

  No

  N/A

• Describe building egress

• HAZCOM adequate

  Yes

  No

  N/A

• All chemicals properly labeled and clearly marked?

  Yes

  No

  N/A

• Chemicals unlabeled

  Media

• Safety training provided to employees

  Yes

  No

  N/A

• Flammable materials present

  Yes

  No

  N/A

• Types of combustibles present

  Select Class A: Common combustible materials (wood, paper, plastic, cloth, rubber,etc) Class B: Flammable and combustible liquids(oils, greases, lacquers, etc), gases and flammable aerosols Class D: Combustible metal powders, flakes, shavings, etc. Class K: Kitchen grease and oil

  • Class A: Common combustible materials (wood, paper, plastic, cloth, rubber,etc)
  • Class B: Flammable and combustible liquids(oils, greases, lacquers, etc), gases and flammable aerosols
  • Class D: Combustible metal powders, flakes, shavings, etc.
  • Class K: Kitchen grease and oil

• Ergonomics Safety and Health Program

  Yes

  No

  N/A

• Walkways uneven, slippery, or obstructed?

  Yes

  No

  N/A

• Uneven, slippery, or obstructed walkways

  Media

• Housekeeping

  Good

  Fair

  Poor

  N/A

• Inadequate housekeeping controls

  Media

• Interior Lighting

  Good

  Fair

  Poor

  N/A

• Inadequate interior lighting

  Media

• Excessive noise

  Yes

  No

  N/A

• Noise reducing PPE available to all employees

  Yes

  No

  N/A

• Computer workstations present

  Yes

  No

  N/A

• adjustable chairs and computer monitors present?

  Yes

  No

  N/A

• Claims or complaints of discomfort or injury from workstation use

  Yes

  No

  N/A

Building Description

• Building Type

  Select School Facility Gymnasium/Field House Physical Plant/Machine Shop Administrative/Office Stadium/Playing Fields Other

  • School Facility
  • Gymnasium/Field House
  • Physical Plant/Machine Shop
  • Administrative/Office
  • Stadium/Playing Fields
  • Other

• Describe building main usage

• Number of students

• Age Range of Students

  Select Pre-K K-8 K-12 Elementary (K-5) Middle School/ Jr. High School (6--8) High School (9-12) College

  • Pre-K
  • K-8
  • K-12
  • Elementary (K-5)
  • Middle School/ Jr. High School (6--8)
  • High School (9-12)
  • College

• Average number of staff present during normal business hours

• Max Occupancy

• Concession Stand Present?

  Yes

  No

  N/A

• Building's primary use

  Garage or equipment storage

  General Storage

  Records Storage

  Machine Shop

  Other

• Describe:

• Are Vehicles/Riding equipment stored overnight?

  Yes

  No

  N/A

• Average number of vehicles stored overnight

• Types of vehicles/equipment stored overnight (check all that apply)

  Select Personal Vehicle Semi-tractor Heavy Construction Box Trucks Heavy-duty pickup Light Construction Equipment Lawnmowers/Landscaping/Agrciculture Equipment School Bus Other

  • Personal Vehicle
  • Semi-tractor
  • Heavy Construction
  • Box Trucks
  • Heavy-duty pickup
  • Light Construction Equipment
  • Lawnmowers/Landscaping/Agrciculture Equipment
  • School Bus
  • Other

• Describe other vehicle types

• Vehicle/equipment fuel kept on site?

  Yes

  No

  N/A

• Fuel stored safely

  Yes

  No

  N/A

• Describe fuel hazards

  Yes

  No

  N/A

• Fuel Storage hazards

  Media

• Average number of staff present during normal business hours

• Regular business Hours

• Max Occupancy

• Concession Stand Present

  Yes

  No

  N/A

• number of playing fields

• Playing field surface

  Grass

  Artificial Turf

  Other

• Field/Turf condition

  Good

  Fair

  Poor

  N/A

• Hazards present?

  Yes

  No

  N/A

• Describe hazards

• Field/Turf hazards

  Media

• Describe field surface

• Swimming Pool present

  Yes

  No

  N/A

• Condition of pool deck

  Good

  Fair

  Poor

  N/A

• Pool perimeter 100% fenced

  Yes

  No

  N/A

• Condition of pool machinery

  Good

  Fair

  Poor

  N/A

• Lifesaving equipment present?

  Yes

  No

  N/A

• Lifeguards present when pool is open?

  Yes

  No

  N/A

• Diving board(s) present?

  Yes

  No

  N/A

• Diving board condition?

  Good

  Fair

  Poor

  N/A

• Diving board hazards present

  Yes

  No

  N/A

• Diving boards

  Media

• Slide present?

  Yes

  No

  N/A

• Slide condition

  Good

  Fair

  Poor

  N/A

• Anti-entrapment device present?

  Yes

  No

  N/A

• Pool VGBPA compliant?

  Yes

  No

  N/A

• GFCI Outlets present

  Yes

  No

  N/A

• Playground(s) present?

  Yes

  No

  N/A

• Check all equipment present

  Select Slide(s) Arch Climber Merry-Go-Round/Spinner Swingset Jungle Gym Chin-up Bar Sandbox Spring rider Trapeze Rings Maze Large play house Small play house Playground Climber Heavy Swings (multiple occupancy/glider) Free swinging ropes Exercise Equipment (Rings, trapeze bars, etc.) Other

  • Slide(s)
  • Arch Climber
  • Merry-Go-Round/Spinner
  • Swingset
  • Jungle Gym
  • Chin-up Bar
  • Sandbox
  • Spring rider
  • Trapeze Rings
  • Maze
  • Large play house
  • Small play house
  • Playground Climber
  • Heavy Swings (multiple occupancy/glider)
  • Free swinging ropes
  • Exercise Equipment (Rings, trapeze bars, etc.)
  • Other

• describe other playground equipment

• Slide exit zones have adequate clearance?

  Yes

  No

  N/A

• Appropriate clearance between swings?

  Yes

  No

  N/A

• Appropriate clearance between swing seats and swing frame

  Yes

  No

  N/A

• Any obstructions in swing path? Appropriate clearance for swing path?

  Yes

  No

  N/A

• Use zone > 72"

  Yes

  No

  N/A

• Playground equipment condition

  Good

  Fair

  Poor

  N/A

• Describe playground hazardous conditions

• Hazardous Playground conditions

  Media

• Play Surface type

  Select Unitary (rubber mats, rubber over foam, rubber tiles, poured in place composites,etc.) Inorganic Loose Fill (sand, gravel, shredded wood, etc) Organic Loose Fill (Wood chips, bark, mulch, etc) Natural surface (grass, dirt, etc) Concrete

  • Unitary (rubber mats, rubber over foam, rubber tiles, poured in place composites,etc.)
  • Inorganic Loose Fill (sand, gravel, shredded wood, etc)
  • Organic Loose Fill (Wood chips, bark, mulch, etc)
  • Natural surface (grass, dirt, etc)
  • Concrete

• Surfacing meets minimum depth requirements

  Yes

  No

  N/A

• Play surface extends 6' in all directions around playground equipment?

  Yes

  No

  N/A

• Play surface condition?

  Good

  Fair

  Poor

  N/A

• Are accessible routes of travel present to meet ADA standards?

  Yes

  No

  N/A

• Portable classrooms present

  Yes

  No

• # of portable structures?

• Steps and porch surfaces in good repair with anti-slip materials on surfaces?

  Yes

  No

  N/A

• Describe hazards and locations

• Step/Stair hazards

  Media

• Exterior lighting?

  Good

  Fair

  Poor

  N/A

• Bleachers present

  Yes

  No

• Bleacher Type

  Permanent/Stationary

  Portable/Moving

  Telescopic/Folding

  Temporary

• Bleacher Construction

  Wood

  Concrete

  Metal

  Other

• Describe Construction

• Guard Rails present on backs and open ends of bleachers

  Yes

  No

  N/A

• Guard Rails ≥ 42" in height

  Yes

  No

  N/A

• Openings ≥ 4" in guardrail sections?

  Yes

  No

  N/A

• Tread/Anti-skid protection present on all stairs

  Yes

  No

  N/A

• Bleachers inspected annually

  Yes

  No

  N/A

• Who is responsible for inspecting bleachers?

• Does construction of bleachers allow access to the sides, underside, or beneath the bleacher structures?

  Yes

  No

  N/A

• Outside Group/Community use of facilities

  Yes

  No

  N/A

• Permits required for use?

  Yes

  No

  N/A

• Certificates of Insurance required

  Yes

  No

  N/A

• Hold Harmless agreements required

  Yes

  No

  N/A

• Security provided by

  School Security

  Private Contractor

  Local/State Police

  Outside groups

  Other

• Are all fields/playing surfaces fenced?

  Yes

  No

  N/A

• Note where fencing is inadequate

  Yes

  No

• Construction

  Select ISO-1 (Frame) ISO-2 (Joisted Masonry) ISO-3 (Non-Combustible) ISO-4 (Masonry Non-Combustible) ISO-5 (Modified Fire Resistive) ISO-6 (Fire Resistive)

  • ISO-1 (Frame)
  • ISO-2 (Joisted Masonry)
  • ISO-3 (Non-Combustible)
  • ISO-4 (Masonry Non-Combustible)
  • ISO-5 (Modified Fire Resistive)
  • ISO-6 (Fire Resistive)

• Are broken windows/doors present?

  Yes

  No

• Water intrusion possible?

  Yes

  No

• Roof Type

  Select Gable Hip Shed Flat Mansard Other

  • Gable
  • Hip
  • Shed
  • Flat
  • Mansard
  • Other

• Roof Condition

  Good

  Fair

  Poor

  N/A

• Hazards Present

  Yes

  No

  N/A

• Describe Hazards and their locations

• Roof Hazards

  Media

• Roof Cover

  Select Composite Shingle Wood BUR Membrane Metal Tar and Gravel Slate Clay/Tile Other

  • Composite Shingle
  • Wood
  • BUR
  • Membrane
  • Metal
  • Tar and Gravel
  • Slate
  • Clay/Tile
  • Other

• Roof cover type description:

• Foundation

  Slab

  Crawl Space

  Piers/ Post-Beam

  Basement

• % Below grade

• Max depth

Building Systems

• Property Inspection Requested

  Yes

  No

• Plumbing

  Good

  Fair

  Poor

  N/A

• Date of last update to plumbing

• Hazards noted

  Yes

  No

  N/A

• Please explain rating

• Identify hazards

  Select Leaks noted Other

  • Leaks noted
  • Other

• Location(s)

• Leaks in plumbing noted

  Media

• Identify other hazards

• Other Hazards

  Media

• Electrical System

  Good

  Fair

  Poor

  N/A

• Explain N/A

• Hazards Present

  Yes

  No

  N/A

• Explain rating

• Choose Hazards

  Select Breaker Panel Improper use of extension cords Junction Box Knob & Tube wiring Aluminum Wiring Wiring presents slip/Trip/Fall hazard Inadequate LOTO procedures Other

  • Breaker Panel
  • Improper use of extension cords
  • Junction Box
  • Knob & Tube wiring
  • Aluminum Wiring
  • Wiring presents slip/Trip/Fall hazard
  • Inadequate LOTO procedures
  • Other

• Describe

• Breaker Panel Hazard(s) identified

  Select Improper panel wiring noted Breaker spaces not filled-in Combustible Material less than 36" from Panel Panel Cover Missing Other

  • Improper panel wiring noted
  • Breaker spaces not filled-in
  • Combustible Material less than 36" from Panel
  • Panel Cover Missing
  • Other

• Describe

• Improper panel wiring

  Media

• Breaker panel space not filled in

  Media

• Combustible material < 36" from panel

  Media

• Panel Cover Missing

  Media

• Note Location

• Improper Use of extension cords

  Media

• Note location(s)

• Please describe

• Junction Box

  Media

• Percentage of building with Knob and tube wiring

• Knob and Tube wiring

  Media

• Percentage of building with Aluminum wiring

• Aluminum Wiring present

  Media

• Note location(s)

• Wiring/Cables/Cords present slip/trip/fall hazard

  Media

• Recommendations for improving LOTO procedures

• Heating/Cooling

  Good

  Fair

  Poor

  N/A

• Hazards Present

  Yes

  No

  N/A

• Explain NA rating

• Hazardous conditions:

  Select Combustible materials within 36" Window AC units improperly installed Waste Oil heaters in use Suspended heaters improperly secured Mold growth noted in ducts Central AC units improperly secured Exposed heating elements present Boiler Present Other hazard noted

  • Combustible materials within 36"
  • Window AC units improperly installed
  • Waste Oil heaters in use
  • Suspended heaters improperly secured
  • Mold growth noted in ducts
  • Central AC units improperly secured
  • Exposed heating elements present
  • Boiler Present
  • Other hazard noted

• Location(s) of combustible materials hazard

• Combustible materials within 36"

  Media

• Describe other hazard

• Locations of improper window unit installation

• Window units improperly installed

  Media

• Waste Oil Heaters in use

  Media

• Suspended heaters improperly secured

  Media

• Mold growth noted in ducts

  Media

• Location of mold growth

• Central ACE units improperly secured

  Media

• Location(s) of improperly secured Central AC unit

• Exposed heating element present

  Media

• Exposed heating element location(s)

• Is boiler located within a reinforced area?

  Yes

  No

  N/A

• Where is Boiler located?

• Is boiler adequately segregated from the interior

  Yes

  No

  N/A

• Boiler location

  Media

• Is Boiler inspected annually

  Yes

  No

  N/A

• Photo of boiler certification

  Media

• Yes

  No

  N/A

Operational and Occupancy Hazards

• Elevators?

  Yes

  No

  N/A

• Capacity

• Number of elevators

• Elevators inspected

  Select Annually Semi-Annually Bi-Annually Quarterly Monthly Elevators not inspected

  • Annually
  • Semi-Annually
  • Bi-Annually
  • Quarterly
  • Monthly
  • Elevators not inspected

• Last insepction date

• Hazardous Chemical Use and Storage

  Yes

  No

  N/A

• HAZCOM policies adequate

  Yes

  No

  N/A

• recommendations for HAZCOM policy improvement

• Hazardous Chemical Storage Adeqaute

  Yes

  No

  N/A

• Are all hazardous chemicals properly labeled?

  Yes

  No

  N/A

• Are all flammable chemicals stored in a non-flammable or metal cabinet?

  Yes

  No

  N/A

• Is access to hazardous chemicals restricted to authorized personnel?

  Yes

  No

  N/A

• Chemical usage is appropriate and in compliance with SDS

  Yes

  No

  N/A

• Commercial Cooking operations

  Yes

  No

  N/A

• Commercial Kitchen present

  Yes

  No

• Hood and Filter present

  Yes

  No

  N/A

• Last inspection date

• Filter Cleaning schedule adequate

  Yes

  No

  N/A

• AES Present?

  Yes

  No

  N/A

• Last Inspection date

• All cooking surfaces covered by AES

  Yes

  No

  N/A

• All nozzles in good condition?

  Yes

  No

  N/A

• Gym/Auditorium Present

  Yes

  No

  N/A

• Secure guards over all lighting

  Yes

  No

  N/A

• Hazards present

  Yes

  No

  N/A

• Describe nature and locations of hazards

• Gym lighting hazards

  Media

• Bleacher Seating and walking surfaces in good condition

  Yes

  No

  N/A

• Bleacher Hazards

  Media

• Retractable basketball backboards fastened securely

  Yes

  No

  N/A

• Walls behind backboards properly padded?

  Yes

  No

  N/A

• Are bleachers present?

  Yes

  No

  N/A

• Types of bleacher

  Fixed Seating

  Telescoping Seating

  Portable Seating

  Auditorium Seating

  Other

• Describe bleachers

• Overall Bleacher/seating condition

  Safe

  At Risk

  N/A

• Are guardrails present?

  Yes

  No

  N/A

• Condition of guardrails

  Good

  Fair

  Poor

  N/A

• Are footboard openings < 4"?

  Yes

  No

  N/A

• Top surface of guardrail 42" above the floor surface?

  Yes

  No

  N/A

• Are bleachers inspected annually?

  Yes

  No

  N/A

• Bleacher surfaces in good condition?

  Yes

  No

  N/A

• Wood Shop Present

  Yes

  No

  N/A

• Dust Collection system present and in good condition

  Yes

  No

  N/A

• Describe dust control methods in place

• Yes

  No

  N/A

• Housekeeping Rating

  Good

  Fair

  Poor

  N/A

• Rating explanation:

• Adequate fire protection present

  Yes

  No

  N/A

• Machine guarding adequate

  Yes

  No

  N/A

• Location(s) of inadequate machine guarding

• Inadequate machine guarding

  Media

• Machine Shop Present

  Yes

  No

  N/A

• Machine guarding adequate and appropriate

  Yes

  No

  N/A

• Inadequate/Improper Machine guarding

  Media

• Location of inadequate/improper machine guarding

• Describe machinery present

• Who has access to the machinery and machine shop?

  Select Faculty Students Maintenance Outside contractors

  • Faculty
  • Students
  • Maintenance
  • Outside contractors

• Welding/Cutting Operations Present

  Yes

  No

  N/A

• Is Welding done in a safe manner?

  Yes

  No

  N/A

• Welding Operations photo

  Media

• Yes

  No

  N/A

• Are compressed gases stored appropriately?

  Yes

  No

  N/A

• Compressed gas storage

  Media

• Unsafe welding operations noted?

  Yes

  No

  N/A

• Unsafe welding/cutting operations

  Media

• Spark Shields present

  Yes

  No

  N/A

• Quality of housekeeping?

  Good

  Fair

  Poor

  N/A

• Fitness Equipment/Weight Room Present

  Yes

  No

  N/A

• Equipment present (check all that apply)

  Select Elliptical Trainers Stationary Bikes Rowing Machines Stair steppers Treadmills Kettle Bells/Free weights Gym/Fitness Machinery (Ex. chest press machine, Smith Machine, Leg press machine,etc.) Other

  • Elliptical Trainers
  • Stationary Bikes
  • Rowing Machines
  • Stair steppers
  • Treadmills
  • Kettle Bells/Free weights
  • Gym/Fitness Machinery (Ex. chest press machine, Smith Machine, Leg press machine,etc.)
  • Other

• Describe other equipment

• Condition of equipment

  Good

  Fair

  Poor

  N/A

• Hazards present?

  Yes

  No

  N/A

• Describe hazards

• Fitness equipment/Weight Room hazards

  Media

• Is equipment regularly inspected and maintained

  Yes

  No

  N/A

• Who maintains the equipment? (department, individual (provide name), outside contractor?)

• Hazards present?

  Yes

  No

  N/A

• Describe hazards

• Fitness equipment/Weight Room hazards

  Media

• Equipment properly secured to floor?

  Yes

  No

  N/A

• Hazards present?

  Yes

  No

  N/A

• Describe hazards

• Fitness equipment/Weight Room hazards

  Media

• Weight racks present?

  Yes

  No

  N/A

• Hazards present?

  Yes

  No

  N/A

• Describe hazards

• Fitness equipment/Weight Room hazards

  Media

• Weight rack condition

  Good

  Fair

  Poor

  N/A

• Hazards present?

  Yes

  No

  N/A

• Describe hazards

• Fitness equipment/Weight Room hazards

  Media

• Quality of housekeeping?

  Good

  Fair

  Poor

  N/A

• Other hazards noted?

  Yes

  No

• At Risk

  Immediate Risk

  Other

• At Risk

  Immediate Risk

  Other

• At Risk

  Immediate Risk

  Other

• At Risk

  Immediate Risk

  Other

• At Risk

  Immediate Risk

  Other

• At Risk

  Immediate Risk

  Other

• At Risk

  Immediate Risk

  Other

• At Risk

  Immediate Risk

  Other

• At Risk

  Immediate Risk

  Other

• At Risk

  Immediate Risk

  Other

• At Risk

  Immediate Risk

  Other

• At Risk

  Immediate Risk

  Other

• At Risk

  Immediate Risk

  Other

• At Risk

  Immediate Risk

  Other

• At Risk

  Immediate Risk

  Other

• At Risk

  Immediate Risk

  Other

• At Risk

  Immediate Risk

  Other

• At Risk

  Immediate Risk

  Other

• At Risk

  Immediate Risk

  Other

• At Risk

  Immediate Risk

  Other

• At Risk

  Immediate Risk

  Other

• At Risk

  Immediate Risk

  Other

• At Risk

  Immediate Risk

  Other

• At Risk

  Immediate Risk

  Other

• At Risk

  Immediate Risk

  Other

Protections/Detection

• Sprinkler System Present

  Yes

  No

  N/A

• Percentage of building covered by Sprinkler System

• Type of Sprinkler System

  Wet

  Dry

  Deluge

  Pre-Action

• Sprinkler System Inspected Annually

  Yes

  No

  N/A

• Date of last sprinkler system inspection

• Hazards present?

  Yes

  No

  N/A

• Describe hazards

• Sprinkler System hazards

  Media

• Alarm systems present

  Select Central Local Fire Department Police Department None

  • Central
  • Local
  • Fire Department
  • Police Department
  • None

• Monitored alarm system

  Yes

  No

  N/A

• Name of monitoring agency/company

• Security system features (Check all that apply)

  Select Video Cameras Video Recording Motion Detectors Security Guards Canine guards Bars on windows/doors Other

  • Video Cameras
  • Video Recording
  • Motion Detectors
  • Security Guards
  • Canine guards
  • Bars on windows/doors
  • Other

• Describe other security system features

• Fire extinguishers present

  Yes

  No

  N/A

• Hazards present?

  Yes

  No

  N/A

• Describe hazards

• Fire Extinguisher hazards

  Media

• Type(S) of Fire extinguishers present

  Select BC ABC D K Other

  • BC
  • ABC
  • D
  • K
  • Other

• Describe Fire Extinguisher

• Date of last inspection

• Adequate number of Fire Extinguishers present?

  Yes

  No

  N/A

• Hazards present?

  Yes

  No

  N/A

• Describe hazards

• Fire Extinguisher hazards

  Media

• Emergency lighting

  Good

  Fair

  Poor

  N/A

• Hazards present?

  Yes

  No

  N/A

• Describe hazards

• Emergency Lighting hazards

  Media

• Building accessible to emergency services and first-responders

  Good

  Fair

  Poor

  N/A

• Describe restrictions on accessibility?

Exterior Hazard

• Emergency Exits Present

  Yes

  No

  N/A

• Describe Emergency Exit procedures

• Exits adequately illuminated?

  Yes

  No

  N/A

• Describe location of exit

• Emergency Exit not adequately illuminated

  Media

• Adequate number of exits provided?

  Yes

  No

  N/A

• Describe emergency exit hazarsd

• Emergency exit hazard

  Media

• Doors equipped with panic hardware

  Yes

  No

  N/A

• Exterior Doors swing out?

  Yes

  No

  N/A

• Emergency Exit hazard and location

• Emergency exit hazard

  Media

• Exterior Stairs Present

  Yes

  No

  N/A

• Exterior stair construction

  Metal

  Wood

  Concrete

  Other

• Exterior stair condition

  Good

  Fair

  Poor

  N/A

• Describe exterior stair hazard and location

• Exterior Stair hazards

  Media

• Hand rails > 42" high?

  Yes

  No

  N/A

• Vertical balusters less than 4" apart?

  Yes

  No

  N/A

• Treads in good condition

  Yes

  No

  N/A

• Exterior stair tread hazard(s) and locations

• Exterior stair tread hazards

  Media

• Exterior lighting

  Good

  Fair

  Poor

  N/A

• Describe lighting hazards and their locations

• Exterior lighting hazards

  Media

• Driveways/Roadway condition

  Good

  Fair

  Poor

  N/A

• Describe roadway/Driveway hazards and locations

• Driveway/Roadway hazards

  Media

• Parking lots present?

  Yes

  No

  N/A

• Square footage

• Parking surface

  Concrete/Pavement

  Dirt/Gravel

  Brick/Stone

  Other

• Describe parking surface

• Parking Lot condition

  Good

  Fair

  Poor

  N/A

• Describe Parking lot hazard conditions and locations

• Parking lot hazard(s)

  Media

• Parking lot striping condition

  Good

  Fair

  Poor

  N/A

• Snow Removal services

  Yes

  No

  N/A

• Who is responsible for snow/ice removal at the location

  Select Employee Contractor Volunteer snow removal services not under member's control Other

  • Employee
  • Contractor
  • Volunteer
  • snow removal services not under member's control
  • Other

• Certificates of Insurance obtained?

  Yes

  No

  N/A

• Name of contractor

• Underground snow/ice melt system in place?

  Yes

  No

  N/A