Monthly Environment/Health/Safety Inspection Form

• Monthly Environmental / Health / Safety Inspection

• Client / Site

• Conducted on

  Date

• Performed by: (First & Last Name)

1 - Housekeeping

• 1.1 Work areas are clean and organized?

  Yes

  No

  N/A

• 1.2 All walking and working surfaces are clear of debris and obstructions?

  Yes

  No

  N/A

• 1.3 Dust Abatement. Work surfaces and facilities are free from dust accumulation?

  Yes

  No

  N/A

• 1.4 Restrooms and break rooms are clean and sanitary? No trash accumulation, no leaks or standing water, lighting is adequate and functional?

  Yes

  No

  N/A

• 1.5 General Signage. Is there missing or faded signage? Does the space require new signage that indicates hazards?

  Yes

  No

  N/A

2 - Tools

• 2.1 Tools are stored properly after use?

  Yes

  No

  N/A

• 2.2 Tools are in good condition and used properly?

  Yes

  No

  N/A

• 2.3 All equipment guards are in place and in good condition?

  Yes

  No

  N/A

• 2.4 Air wands have approved tips?

  Yes

  No

  N/A

3 - PPE - Personal Protective Equipment

• 3.1 PPE is worn properly?

  Yes

  No

  N/A

• 3.2 Required PPE available for employees at the site?

  Yes

  No

  N/A

• 3.3 PPE is in good condition and suitable for the job?

  Yes

  No

  N/A

4 - Fire Extinguishers

• 4.1 Extinguishers are accessible / free from blockage?<br>

  Yes

  No

  N/A

• 4.2 Charged and Serviced? Monthly Inspection card is current?

  Yes

  No

  N/A

• 4.3 Extinguishers are are well marked / easily located?

  Yes

  No

  N/A

• 4.4 Extinguishers are in good repair?

  Yes

  No

  N/A

• 4.5 The proper extinguishing agent is available for the potential fire hazard? (CO2, Water, Foam, Chemical?)

  Yes

  No

  N/A

5 - Emergency Exits

• 5.1 All emergency exits are accessible and free from obstruction?

  Yes

  No

  N/A

• 5.2 Clearly marked and visible from all vantage points in the area? Signage is adequate to met the need?

  Yes

  No

  N/A

• 5.3 Exit doors open outwards?

  Yes

  No

  N/A

• 5.4 Doors have the correct opening device?

  Yes

  No

  N/A

• 5.5 Exit lanes are at least 4 feet wide?

  Yes

  No

  N/A

6 - Emergency Lighting

• 6.1 Adequate lighting available and operational?

  Yes

  No

  N/A

7 - First Aid / Medical Equipment

• 7.1 Trauma Kits accessible and free from obstructions? Properly maintained and serviced?

  Yes

  No

  N/A

• 7.2 AED unit(s) accessible and free from obstructions? Properly maintained and serviced?

  Yes

  No

  N/A

• 7.3 First Aid cabinets accessible and free from obstruction? Materials stocked?

  Yes

  No

  N/A

• 7.4 Eye wash stations accessible and free from obstructions? Properly maintained and serviced? Tested?

  Yes

  No

  N/A

8 - Hazardous Materials

• 8.1 Labeled properly?

  Yes

  No

  N/A

• 8.2 Flammables / Chemicals / Gas stored properly in appropriate and approved storage devices?

  Yes

  No

  N/A

• 8.3 Gas cylinders properly stored and in good condition?

  Yes

  No

  N/A

• 8.4 Gas turned off when not in use?

  Yes

  No

  N/A

• 8.5 Spill kits available? Properly stocked with materials required to respond to spills?

  Yes

  No

  N/A

9 - Fall Protection

• 9.1 Handrails installed on all areas 6 feet or higher?

  Yes

  No

  N/A

• 9.2 Handrails installed on all stairs?

  Yes

  No

  N/A

• 9.3 Handrails meet standard 42", mid-rail, and toe board specifications?

  Yes

  No

  N/A

• 9.4 Ladders are in good condition and secure? Rust, damage to rungs or supports? Securely fastened at all control points?

  Yes

  No

  N/A

• 9.5 Fixed ladders have provide cage above 6 feet?

  Yes

  No

  N/A

• 9.6 Harnesses are available and in proper working condition?

  Yes

  No

  N/A

10 - Hoists / Cranes / Come-a-Longs

• 10.1 Inspected and in good condition?

  Yes

  No

  N/A

• 10.2 Rated for capacity?

  Yes

  No

  N/A

• 10.3 Supporting structure rated for capacity?

  Yes

  No

  N/A

• 10.4 Safety latch on hook and in proper working condition?

  Yes

  No

  N/A

11 - Electrical

• 11.1 MCC's labeled properly?

  Yes

  No

  N/A

• 11.2 MCC doors closed and in good condition?

  Yes

  No

  N/A

• 11.3 Three (3) foot clearance in front of all MCC's?

  Yes

  No

  N/A

• 11.4 Cords and cables stored properly? Good condition?

  Yes

  No

  N/A

• 11.5 GFCI's installed for all components within 6' of a water source?

  Yes

  No

  N/A

12 - Guarding

• 12.1 All moving equipment guarded?

  Yes

  No

  N/A

• 12.2 Drive shafts, sprockets, pulleys and chains?

  Yes

  No

  N/A

• 12.3 Hazardous areas clearly marked? Signage in good condition?

  Yes

  No

  N/A

• 12.4 Confined spaces / High traffic areas / Lockout areas properly guarded?

  Yes

  No

  N/A

13 - Corrective Action Requests

• 13.1 Did the audit result in any findings? If YES, enter CAR numbers pulled for each finding in the text field in section 13.2

  Yes

  No

  N/A

• Section 13.2