Limited Lift Audit - Local

• Limited Lift

• Conducted on

  Date

• Prepared by

• Location
  Address

• Hosted by:

Intro Notes/Discussion:

• Yes

  No

  N/A

Claim Reporting

• Claim Reporting Policy in place?

  Yes

  No

  N/A

• 24 hour notification of work place injury?

  Yes

  No

  N/A

RTW

• Organization has a RTW policy that consistently accommodates modified duty?

  Yes

  No

  N/A

• Each department has a list of restricted/modified duty jobs for consideration?

  Yes

  No

  N/A

DMP

• Designated Medical Provider?

  Yes

  No

  N/A

• Provider is occupational/industrial medicine specialist?

  Yes

  No

  N/A

Drug and Alcohol Controls & Testing

• Does the organization have PADT policy in place?

  Yes

  No

  N/A

• Does organization perform reasonable suspicion testing with supportive policy controls?

  Yes

  No

  N/A

• Verify post accident drug testing<br>

  Yes

  No

  N/A

Job Descriptions

• Job descriptions are reviewed annually with accurate essential physical demands listed?

  Yes

  No

  N/A

• Essential Physical Demands:<br>

  Yes

  No

  N/A

1.0 Limited Lift

• 1.1 - Acuity Review:

  Yes

  No

  N/A

• 1.2 - Lift Inventory:

  Yes

  No

  N/A

• Disciplinary Review for policy violations:

  Yes

  No

  N/A

• Sling Inspection:

  Yes

  No

  N/A

• Maintenance Protocols:

  Yes

  No

  N/A

• Number of IND transfers:<br>List by wing:

  Yes

  No

  N/A

• 1 person transfers:

  Yes

  No

  N/A

• Sit<>Stand:

  Yes

  No

  N/A

• Total/Full Lift:

  Yes

  No

  N/A

• Sit<>Stand inventory:

  Yes

  No

  N/A

• Total Lift Inventory:

  Yes

  No

  N/A

• Sling Inspection Audit:

  Yes

  No

  N/A

• Maintenance Schedule:

  Yes

  No

  N/A

• RH injuries last:<br>Quarter:<br>6 months:<br>1 year:

  Yes

  No

  N/A

2.0 - Fire Prevention

• 2.1 - Evacuation plan displayed and understood by all employees?

  Yes

  No

  N/A

• 2.3 - Extinguishers in place, clearly marked for type of fire?

  Yes

  No

  N/A

• 2.2 - Evacuation procedures discussed regularly? (3 to 4 times a year)

  Yes

  No

  N/A

• 2.4 - Extinguishers recently serviced? (Check 6 monthly punch mark on tabs.)

  Yes

  No

  N/A

• 2.5 - Extinguishers clear of obstructions?

  Yes

  No

  N/A

• 2.6 - Extinguisher no more than 1200 mm max height & base not lower that 100 mm?

  Yes

  No

  N/A

• 2.7 - Indicator signs 2.1 m above floor level?

  Yes

  No

  N/A

• 2.8 - Adequate direction notices for fire exits?

  Yes

  No

  N/A

• 2.9 - Exit doors easily opened from inside?

  Yes

  No

  N/A

• 2.10 - Exits clear of obstructions?

  Yes

  No

  N/A

• 2.11 - Fire alarm system functioning correctly?

  Yes

  No

  N/A

3.0 - General Lighting

• 3.1 - Good natural lighting?

  Yes

  No

  N/A

• 3.2 - Reflected light from walls & ceilings not causing glare to employees?

  Yes

  No

  N/A

• 3.3 - Light fittings clean and in good condition?

  Yes

  No

  N/A

• 3.4 - Emergency exit lighting operable?

  Yes

  No

  N/A

4.0 - Building Safety

• 4.1 - Floor surfaces even and uncluttered?

  Yes

  No

  N/A

• 4.2 - Entry and walkways kept clear?

  Yes

  No

  N/A

• 4.3 - Walkways adequately and clearly marked?

  Yes

  No

  N/A

• 4.4 - Intersections kept clear of boxes etc?

  Yes

  No

  N/A

• 4.5 - Stair and risers kept clear?

  Yes

  No

  N/A

• 4.6 - Are liquid spills removed quickly?

  Yes

  No

  N/A

• 4.7 - Are railings in good condition?

  Yes

  No

  N/A

• 4.8 - Are fall preventive measures in place and used where gaps occur in railings?

  Yes

  No

  N/A

• 4.9 - Are footpaths in good condition?

  Yes

  No

  N/A

• 4.10 - Furniture in sound condition?

  Yes

  No

  N/A

• 4.11 - Loading area clean and tidy?

  Yes

  No

  N/A

11.0 Ladders

• 11.1 - Are all ladders Industrial strength? (Non Household rated, check label.)

  Yes

  No

  N/A

• 11.2 - Are ladders in good condition?

  Yes

  No

  N/A

• 11.3 - If used for electrical work are they non conductive? (Wood or fibre glass.)

  Yes

  No

  N/A

• 11.4 - Used according to instructions?

  Yes

  No

  N/A

• 11.5 - For extension ladders are ropes, pulleys and treads in a good state of repair?

  Yes

  No

  N/A

14.0 - Vehicle Condition

• MVR Policy?

  Yes

  No

  N/A

• 14.1 - Schedule maintenance performed?

  Yes

  No

  N/A

• 14.2 - Condition of tyres?

  Yes

  No

  N/A

• 14.3 - Brake performance?

  Yes

  No

  N/A

• 14.4 - Lights? (Check operation of brake, indicator and reversing lights)

  Yes

  No

  N/A

• 14.5 - Condition of drivers seat?

  Yes

  No

  N/A

• 14.6 - Condition of other seats?

  Yes

  No

  N/A

• 14.7 - First aid kit supplied and adequate?

  Yes

  No

  N/A

• 14.8 - Storage provisions?

  Yes

  No

  N/A

Sign Off

• On site representative

  Sign

• Auditor's signature

  Sign