Midwest region Safety Audit Form

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Personal Protective equipment

• Is Employee wearing Knee pads?

  Yes

  No

  N/A

• Does employee have a ladder / step stool ?

  Yes

  No

  N/A

• Does employee have gloves and safety knife?

  Yes

  No

  N/A

• Is employee wearing non-slip shoes?

  Yes

  No

  N/A

Vehicle ( company asset )

• Is the asset DOT regulated?

  Yes

  No

  N/A

• Does vehicle have spill kit ( is putty pliable ) ?

  Yes

  No

  N/A

• Does the asset have insurance card / registration / accident kit?

  Yes

  No

  N/A

• Did employee conduct a Pre-trip inspection to include fluids under the hood?

  Yes

  No

  N/A

• Does the asset have working locks and doors?

  Yes

  No

  N/A

Living safely

• Does employee know the importance of maintaining proper hydration and diet?

  Yes

  No

  N/A

• Does employee know importance of proper rest?

  Yes

  No

  N/A

• Does employee take micro breaks and stretch throughout the work day?

  Yes

  No

  N/A

Work Habits

• Does employee lift properly?

  Yes

  No

  N/A

• Does employee handle boxes and cardboard properly?

  Yes

  No

  N/A

• Does employee use three point of contact when entering and exiting the truck?

  Yes

  No

  N/A

• Does the employee use ESPN when going about their daily business?

  Yes

  No

  N/A

Truck Procedures

• Is the truck neat, clean and organized?

  Yes

  No

  N/A

• Does employee use case hook?

  Yes

  No

  N/A

• Does employee strap load in and secure handcart?

  Yes

  No

  N/A

• Does employee lock asset?

  Yes

  No

  N/A

• Does employee use the circle of safety and use parking cones?

  Yes

  No

  N/A

Living Safely

• What is employee doing to make safety part of their work and home life?

  Yes

  No

  N/A

• What does employee do to advocate a safe working environment?

  Yes

  No

  N/A

• How many years / months has the employee worked safely with out incident?

  Yes

  No

  N/A

Safety Concerns / ideas

• Enter comments here

  Yes

  No

  N/A

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