Intro Notes/Discussion:

Claim Reporting

Claim Reporting Policy in place?

24 hour notification of work place injury?


Organization has a RTW policy that consistently accommodates modified duty?

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


Designated Medical Provider?

Provider is occupational/industrial medicine specialist?

Drug and Alcohol Controls & Testing

Does the organization have PADT policy in place?

Does organization perform reasonable suspicion testing with supportive policy controls?

Verify post accident drug testing

Job Descriptions

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

Essential Physical Demands:

1.0 Limited Lift

1.1 - Acuity Review:

1.2 - Lift Inventory:

Disciplinary Review for policy violations:

Sling Inspection:

Maintenance Protocols:

Number of IND transfers:
List by wing:

1 person transfers:


Total/Full Lift:

Sit<>Stand inventory:

Total Lift Inventory:

Sling Inspection Audit:

Maintenance Schedule:

RH injuries last:
6 months:
1 year:

2.0 - Fire Prevention

2.1 - Evacuation plan displayed and understood by all employees?

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

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

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

2.5 - Extinguishers clear of obstructions?

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

2.7 - Indicator signs 2.1 m above floor level?

2.8 - Adequate direction notices for fire exits?

2.9 - Exit doors easily opened from inside?

2.10 - Exits clear of obstructions?

2.11 - Fire alarm system functioning correctly?

3.0 - General Lighting

3.1 - Good natural lighting?

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

3.3 - Light fittings clean and in good condition?

3.4 - Emergency exit lighting operable?

4.0 - Building Safety

4.1 - Floor surfaces even and uncluttered?

4.2 - Entry and walkways kept clear?

4.3 - Walkways adequately and clearly marked?

4.4 - Intersections kept clear of boxes etc?

4.5 - Stair and risers kept clear?

4.6 - Are liquid spills removed quickly?

4.7 - Are railings in good condition?

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

4.9 - Are footpaths in good condition?

4.10 - Furniture in sound condition?

4.11 - Loading area clean and tidy?

11.0 Ladders

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

11.2 - Are ladders in good condition?

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

11.4 - Used according to instructions?

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

14.0 - Vehicle Condition

MVR Policy?

14.1 - Schedule maintenance performed?

14.2 - Condition of tyres?

14.3 - Brake performance?

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

14.5 - Condition of drivers seat?

14.6 - Condition of other seats?

14.7 - First aid kit supplied and adequate?

14.8 - Storage provisions?

Sign Off
On site representative
Auditor's signature
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.