Information

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Number of Personnel

Ergonomics - Body Posture

  • Lifting/Bending in the strike zone (thigh to chest levels)

  • Reaching/Twisting (reaching low and to the side -- stretching up and to the side)

  • Pushing/Pulling (push good - pull bad)

  • Posture (back, arm, head, shoulders, and truck straight?)

  • Awkward posture sustained (more than 5 seconds before relaxing?)

  • Two person lift used (material over 50lbs or bulk items)

  • F - Use of seatbelt

  • G- proper use of forks (secured loads, used for lifting or transporting only)

  • H- Proper use of chokers, clamps, chains, etc..

  • Misc. Notes

  • Misc. Picture

Behavioral Observations

  • Unsafe behaviors observed - Actions taken to correct & prevent reoccurrence

  • Safe behaviors observed - Actions taken to encourage safe behavior

Work Environment

Work Environment

  • Weather temperature?

  • Wind speed?

  • Furniture & chairs are in good stable condition

  • Work Areas:Clean, sanitary, & orderly

  • Items stored properly to avoid tripping & falling

  • Debris and scrap stored safely

  • PPE is readily available and well maintained

  • Areas requiring PPE have adequate warning signs posted , and usage is enforced

  • Work area is adequately illuminated <br><br>

  • Aisles and passageways are clear

  • Material Storage - Sharp projections do not interfere with the walkways

  • All aisles maintain a safe clearance (3 feet minimum)

  • Job trailer areas maintained outside

  • Hot work areas free of combustibles and flammables (35 feet/ fire blankets?)

  • Are all exits free of obstructions

Equipment

  • Ladders are in good condition (no cracks, damage to rungs, rails, braces, steps, etc..)

  • All tools & equipment are in good working condition (corded devices have no frayed or exposed wires)

Chemicals

  • All chemicals are clearly marked & labeled

  • Appropriate PPE (when applicable) provided, used, & maintained

First Aid

  • First aid kits are wall mounted, fully stocked & clearly marked

  • Emergency Eye wash station is properly maintained & inspected (check date on saline solution)

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.