NPS Safety

• Site conducted

  Select
• Location
  Address

• Exterior Photo

  Media

• Date of Inspection

  Date

• Inspected by

  Select

• Housing Inspection

• Is the house number visible from the street?

  Yes

  No

  N/A

• Is the property free of the accumulation of rubbish, trash, brush or tree trimmings?

  Yes

  No

  N/A

• Are wood piles further than 30’ away from any building?

  Yes

  No

  N/A

• Are service entrance raceways or cables fastened in place, grounded, readily accessible and in good condition?

  Yes

  No

  N/A

• If Garage is attached is a barrier wall between the garage and house present and serviceable? (I.e free from mold, voids and damage.)

  Yes

  No

  N/A

• Is there a solidcore door between the garage and residence? (Fire rated?)

  Yes

  No

  N/A

• If Garage is detached, is a second 5lb 2A fire extinguisher provided?

  Yes

  No

  N/A

• Are outside electrical receptacles GFCI and in good working condition?

  Yes

  No

  N/A

• Is gas powered equipment stored in an outside shed or garage, separate from the living areas?

  Yes

  No

  N/A

• Are flammable and combustible fluids stored in an approved container in an outside shed or garage, separate from the living areas?

  Yes

  No

  N/A

• Are lighting fixture canopies fastened in place and are fixture is in good condition? EXTERIOR

  Yes

  No

  N/A

• Is there a fire extinguisher in the home?

  Yes

  No

  N/A

• Minimum required 5lb 2A?

  Yes

  No

  N/A

• Mounted properly, accessible, and fully charged? Is the tamper seal intact, a valid contractor’s inspection tag present and are monthly visual inspections performed?

  Yes

  No

  N/A

• Smoke alarms present?

  Yes

  No

  N/A

• Located in every bedroom?

  Yes

  No

  N/A

• Located on every level?

  Yes

  No

  N/A

• located outside each separate sleeping area?

  Yes

  No

  N/A

• Checked that smoke alarm is free of physical damage, interconnected, and under 10 years old?

  Yes

  No

  N/A

• Have all smoke alarms been checked IAW manufacturer recommendations?

  Yes

  No

  N/A

• Have all carbon monoxide (CO) Detectors been checked IAW manufacturer recommendations and free from damage and unexpired(5-7years old)?

  Yes

  No

  N/A

• Do all rooms have 2 exit routes? (multi-story homes requires accessible ladders)

  Yes

  No

  N/A

• Are windows used for escape in serviceable condition?

  Yes

  No

  N/A

• Is electrical panel and distribution equipment accessible, labeled, and in good condition?

  Yes

  No

  N/A

• Are outlets located within 6 feet of a water source GFCI protected?

  Yes

  No

  N/A

• Are all receptacle and switch face plates are installed and in good condition?

  Yes

  No

  N/A

• Are the bulbs in light fixtures the correct wattage for the lighting fixture?

  Yes

  No

  N/A

• Are lighting fixture canopies fastened in place and are fixture is in good condition? INTERIOR

  Yes

  No

  N/A

• Are surge protectors (power strips) being used properly?

  Yes

  No

  N/A

• Flexible cords and cables are NOT being used as fixed wiring, run through holes in walls, ceiling or floor, run through doorways or windows or under carpets or attached to building surfaces?

  Yes

  No

  N/A

• The home is not cluttered with clothes, magazines, newspapers and other items that can burn?

  Yes

  No

  N/A

• Are combustibles stored at least 3 feet from space heaters, fireplaces, stoves, and furnaces?

  Yes

  No

  N/A

• Are Flammable and combustible liquids stored in the home and in limited quantities?

  Yes

  No

  N/A

• Are there propane heating appliances, or other open burning appliances in the residence?

  Yes

  No

  N/A

• Are the appliances serviceable?

  Yes

  No

  N/A

• Is the furnace inspection accomplished yearly and properly documented?

  Yes

  No

  N/A

• Does the building have a fireplace?

  Yes

  No

  N/A

• Is an ash can in place for fireplace cleaning?

  Yes

  No

  N/A

• Is the screen in place?

  Yes

  No

  N/A

• Has the fireplace been serviced and cleaned in the last 12months? (ie flute cleaned)

  Yes

  No

  N/A

• Does the home have a serviceable radon mitigation system?

  Yes

  No

  N/A

• Date of last inspection?

  Date

• Install date?

  Date

• Has the furnace inspection been verified and completed within the last 12months IAW.......?

  Yes

  No

  N/A

• Date of last inspection

  Date

• Does the building have a fire alarm system?

  Yes

  No

  N/A

• Proof of annual Inspection, Testing, and/or Maintenance?

  Yes

  No

  N/A

• Are the fire alarm system inspections conducted by a third party?

  Yes

  No

  N/A

• Is there a sprinkler system in the home?

  Yes

  No

  N/A

• Has this system been inspected annually by a competent person?

  Yes

  No

  N/A

• Are all water supply valves open, and secured in open position?

  Yes

  No

  N/A

• Verify designed static pressure (from placard if available) and record static water pressure on riser gauge?

  Yes

  No

  N/A

• Where applicable, test water flow switch. Do exterior notification device sound within 90 seconds?

  Yes

  No

  N/A

• Test of antifreeze solution

  Yes

  No

  N/A

• Is the water tank (if applicable) is at an acceptable level?

  Yes

  No

  N/A

• Is the sprinkler pump (if applicable) fully operational?

  Yes

  No

  N/A

• Does visual inspection of all sprinklers maintain 18 inches free and clear around sprinkler heads?

  Yes

  No

  N/A

• Rating of house clutter

• Are the current tenants aware of the dangers that come with Asbetos management plan and Lead within the home?

• NOTES

• undefined

• General building

• Is the building structural sound and otherwise in good condition?

  Yes

  No

  N/A

• Are grounds surrounding the facility clear of accumulations of combustible material and brush?

  Yes

  No

  N/A

• Are there signs of rodent or other animal intrusion?

  Yes

  No

  N/A

• Are all defects, such as floor tiles, broken steps, torn carpet or curled mats identified until repaired or replaced

  Yes

  No

  N/A

• Are the exterior emergency exit routes kept clear and free from snow and ice or other obstructions or trip and fall hazards?

  Yes

  No

  N/A

• Are electrical enclosures such as switches, receptacles, and junction boxes provided with undamaged, tight-fitting covers, or plates, including plugged unused opening (knockouts)? 29 CFR 1910.305(b)(1) 29 CFR 1910.305(b)(2)

  Yes

  No

  N/A

• Are safety equipment items available, mounted, and current? (e.g., fire extinguishers, smoke and CO detectors, and first aid kits) 29 CFR 1910.157(c)(1) 29 CFR 1910.151(b)

  Yes

  No

  N/A

• Are flammable/combustible liquids kept in approved safety containers?

  Yes

  No

  N/A

• Are bagged materials, containers, bundles, etc., stored in tiers stacked, blocked, interlocked and limited in height so that they are stable and secure against sliding or collapse?

  Yes

  No

  N/A

• Are hazardous materials labels affixed to containers maintained in good condition and not defaced, torn or otherwise damaged that would prevent the label from being legible?

  Yes

  No

  N/A

• Are soiled rags kept in an approved and listed, self-closing, noncombustible container?

  Yes

  No

  N/A

• Has the weight capacity for overhead storage been approved by a Professional Engineer and permanently marked in a conspicuous location for the storage area?

  Yes

  No

  N/A

• Workers have been trained and can navigate https://glacier.kha.com/?

  Yes

  No

  N/A

• Trailer Pad Inspection

• Is the area clear of any Hazardous tree's or dead branches that could fall?

  Yes

  No

  N/A

• Are picnic tables and fire rings serviceable?

  Yes

  No

  N/A

• Is adequate clearance provided in front of electrical service panels and disconnects? 29 CFR 1910.303(g)(1)(i)

  Yes

  No

  N/A

• Are all disconnecting switches and circuit breakers each labeled to indicate their use or equipment served? 29 CFR 1910.303(f)

  Yes

  No

  N/A

• Do circuit breakers clearly indicate whether they are in the “on” or “off” position? 29 CFR 1910.304(e)(1)(vi)

  Yes

  No

  N/A

• Are electrical enclosures such as switches, receptacles, and junction boxes provided with undamaged, tight-fitting covers, or plates, including plugged unused opening (knockouts)? 29 CFR 1910.305(b)(1) 29 CFR 1910.305(b)(2)

  Yes

  No

  N/A

• Dorm Inspection

• Do all rooms have 2 exit routes?

  Yes

  No

  N/A

• Do windows used for escape open easily?

  Yes

  No

  N/A

• Is electrical panel and distribution equipment accessible and in good condition?

  Yes

  No

  N/A

• Are outlets located within 6 feet of water source GFCI protected?

  Yes

  No

  N/A

• Are all receptacle and switch face plates are installed and in good condition?

  Yes

  No

  N/A

• Are the bulbs in light fixtures the correct wattage for the lighting fixture?

  Yes

  No

  N/A

• Are lighting fixture canopies fastened in place and are fixture is in good condition? INTERIOR

  Yes

  No

  N/A

• Are surge protectors (power strips) being used properly?

  Yes

  No

  N/A

• Flexible cords and cables are NOT being used as fixed wiring, run through holes in walls, ceiling or floor, run through doorways or windows or under carpets or attached to building surfaces?

  Yes

  No

  N/A

• The home is not cluttered with clothes, magazines, newspapers and other items that can burn?

  Yes

  No

  N/A

• Things that can burn are at least 3 feet from space heaters, fireplaces, and furnaces?

  Yes

  No

  N/A

• Are Flammable liquids, if stored in the home, limited in quantity?

  Yes

  No

  N/A

• Does the home have carbon monoxide (CO) Detectors that are free of damage and unexpired?

  Yes

  No

  N/A

• Is there a fire extinguisher in the home?

  Yes

  No

  N/A

• Minimum rating of 2A?

  Yes

  No

  N/A

• Mounted properly, accessible, and fully charged? Is the tamper seal intact, a valid contractor’s inspection tag present and are monthly visual inspections performed?

  Yes

  No

  N/A

• Smoke alarms present?

  Yes

  No

  N/A

• Located in every bedroom?

  Yes

  No

  N/A

• Located on every level?

  Yes

  No

  N/A

• located outside each separate sleeping area?

  Yes

  No

  N/A

• free of physical damage, interconnected, and unexpired?

  Yes

  No

  N/A

• Does the building have a fire alarm system?

  Yes

  No

  N/A

• Proof of annual Inspection, Testing, and/or Maintenance?

  Yes

  No

  N/A

• Are the fire alarm system inspections conducted by a third party?

  Yes

  No

  N/A

• Is there a sprinkler system in the home?

  Yes

  No

  N/A

• Has this system been inspected by a competent person?

  Yes

  No

  N/A

• Are all water supply valves open, and secured in open position?

  Yes

  No

  N/A

• Do visual inspection of all sprinklers shows they are not blocked, or being used to support decorations, and are not leaking or damaged?

  Yes

  No

  N/A

• Vault toilet inspection

• Is the exterior/interior of the vault toilet structurally sound and in good repair (walls, roof, flooring, doors, etc.)?

  Yes

  No

  N/A

• Do doors open without obstruction?

  Yes

  No

  N/A

• Are all ventilation openings on the vault toilet screened and clear of debris?

  Yes

  No

  N/A

• Is hand sanitizer and toilet paper available?

  Yes

  No

  N/A

• Are the vault toilet risers and lids cleaned and in good shape?

  Yes

  No

  N/A

• Is vegetation or brush piled up more then 30ft away from the building that could cause structural damage during a fire?

  Yes

  No

  N/A

• Swing gate inspection

• Is the gate properly secured when in the open or closed position?

  Yes

  No

  N/A

• Is the swing gate in working order to include attached locking devices?

  Yes

  No

  N/A

• When gate arms are in the vertical position or rotated to an open position, does closest part of the gate arm and support have a lateral offset of at least 2 feet from the face of the curb or the edge of the traveled way?

  Yes

  No

  N/A

• Is the gate on a two way road?

  Yes

  No

  N/A

• Are both sides of the gate reflectorized?

  Yes

  No

  N/A

• Workshop inspection

• Lock out tag out

  Yes

  No

  N/A

Environment

• Are all area's kept organized and clean? 29 CFR 1910.22.(a)

  Yes

  No

  N/A

• Are aisles and passageways kept clear and in good repair? 29 CFR 1910.22(b)(1)

  Yes

  No

  N/A

• Are walking surfaces kept dry or appropriate means taken to ensure that surfaces are slip-resistant? 29 CFR 1910.22(a)(2)

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Is combustible scrap, debris, and waste stored safely and removed from the worksite promptly? 29 CFR 1910.106(e)(9) (iii)

  Yes

  No

  N/A

• Are toilets and washing facilities sanitary? 29 CFR 1910.141(d)

  Yes

  No

  N/A

• Are enclosed workplaces constructed, equipped, and maintained, so far as reasonably practicable, as to prevent the entrance or harbor age of rodents, insects, and other vermin? 29 CFR 1910.141(a)(5)<br><br>

  Yes

  No

  N/A

• Are all work areas adequately lighted? 29 CFR 1910.22(a)

  Yes

  No

  N/A

• Are safety equipment items available, mounted, and current? (e.g., fire extinguishers, smoke and CO detectors, and first aid kits) 29 CFR 1910.157(c)(1) 29 CFR 1910.151(b)

  Yes

  No

  N/A

• Are fire extinguishers mounted 4 inches minimum off the ground maximum of 5 feet from the top of extinguisher weighing less then 40 lbs. and 3.5 feet from the top of extinguisher weighing more then 40 lbs. NFPA 10

  Yes

  No

  N/A

Emergency Procedures

• Written evacuation procedures and exits displayed

  Yes

  No

  N/A

• Are spill kits available?

  Yes

  No

  N/A

• Portable fire extinguishers have been provided and maintained.

  Yes

  No

  N/A

• Escape routes and emergency doors are clear with working emergency lighting.

  Yes

  No

  N/A

• Are the exit signs free of visual obstructions, can they be easily seen and are illuminated exit signs all lit?

  Yes

  No

  N/A

• Have fire drills been conducted and documented? (over 11 occupants)

  Yes

  No

  N/A

• If a fire alarm system exists, can facility manager show proof of Inspection, Testing, and/or Maintenance?

  Yes

  No

  N/A

Stairways

• Are standard stair rails and handrails present on all stairways having four or more risers? 29 CFR 1910.23(d)(1)

  Yes

  No

  N/A

• Do stairs angle no more than 50 degrees and no less than 30 degrees? 29 CFR 1910.24(e)

  Yes

  No

  N/A

• Are step risers on stairs uniform from top to bottom, with no riser spacing greater than 9.5 inches? Are these areas well lit? 29 CFR 1910.24(e) 29 CFR 1910.24(f)

  Yes

  No

  N/A

• Are steps on stairs and stairways designed or provided with a slip resistant surface? 29 CFR 1910.24(c)

  Yes

  No

  N/A

• Are stairway handrails located between 30-34 inches above the leading edge of stair treads? 29 CFR 1910.23(e)(5)(ii)

  Yes

  No

  N/A

• Are stairway handrails capable of withstanding a load of 200 pounds applied in any direction? 29 CFR 1910.23(e)(5)(iv) UBC 1607.3.4

  Yes

  No

  N/A

• Where stairs or stairways exit directly into any area where vehicles may be operated, are adequate barriers and warnings provided to prevent employees from stepping into the path of traffic? 29 CFR 1910.23(c)

  Yes

  No

  N/A

• Are stairways free of defects, rubbish, slippery substances, loose materials, or obstructions that may cause slips, trips, and falls?

  Yes

  No

  N/A

Storage

• Racking securely fixed to the floor or wall.

  Yes

  No

  N/A

• Is a space of at least 18 inches (457 mm) kept between sprinkler heads and materials?

  Yes

  No

  N/A

• Has the weight capacity for overhead storage been approved by a Professional Engineer and permanently marked in a conspicuous location for the storage area?

  Yes

  No

  N/A

Electrical Safety

• Are electrical cords free of splices or taps? 29 CFR 1910.305(g)(2)(ii)

  Yes

  No

  N/A

• Are all disconnecting switches and circuit breakers each labeled to indicate their use or equipment served? 29 CFR 1910.303(f)

  Yes

  No

  N/A

• Do circuit breakers clearly indicate whether they are in the “on” or “off” position? 29 CFR 1910.304(e)(1)(vi)

  Yes

  No

  N/A

• Is adequate clearance provided in front of electrical service panels and disconnects? 29 CFR 1910.303(g)(1)(i)

  Yes

  No

  N/A

• Are all lights located within 7 feet of the floor, or exposed to being struck or damaged, protected?

  Yes

  No

  N/A

• Are electrical enclosures such as switches, receptacles, and junction boxes provided with undamaged, tight-fitting covers, or plates, including plugged unused opening (knockouts)? 29 CFR 1910.305(b)(1) 29 CFR 1910.305(b)(2)

  Yes

  No

  N/A

• Are electrical outlets prohibited above permanently installed electric heaters? NEC 424.9

  Yes

  No

  N/A

• Are electrical appliances such as vacuum cleaners, portable heaters, and vending machines grounded? 29 CFR 1910.304(f)(5)

  Yes

  No

  N/A

• Do all extension cords have a grounding conductor? 29 CFR 1910.334(a)(3)

  Yes

  No

  N/A

• Are extension cords protected from abrasion, crushing, kinking, and pulling?

  Yes

  No

  N/A

• Are exposed wiring and cords with frayed or deteriorated insulation repaired or replaced promptly? 29 CFR 1910.334(a)(2) (I) 29 CFR 1910.303(b)(iii)

  Yes

  No

  N/A

Chemical Aspects

• Workers have been trained and can navigate https://glacier.kha.com/?

  Yes

  No

  N/A

• Are hazardous materials labels affixed to containers maintained in good condition and not defaced, torn or otherwise damaged that would prevent the label from being legible?

  Yes

  No

  N/A

• Are soiled rags kept in an approved and listed, self-closing, noncombustible container?

  Yes

  No

  N/A

• Only flammables stored in flammable liquid cabinet?

  Yes

  No

  N/A

• Are HAZMAT incompatible materials separated per NFPA 60.5.1.12.2

  Yes

  No

  N/A

• Are the warning signs on the cabinet legible? (e.g. DG Class 3 diamond, no smoking, no ignition sources).

  Yes

  No

  N/A

Personal Protective Equipment

• Do supervisors ensure that PPE is provided, used, and maintained in a sanitary serviceable condition?

  Yes

  No

  N/A

• signage of PPE requirements displayed on equipment.

  Yes

  No

  N/A

• Required PPE available

  Yes

  No

  N/A

• Appropriate signs displayed to standard requirements visible, correctly located and in good condition, (Inside and outside).

  Yes

  No

  N/A

Machinery

• Are abrasive wheel work rests adjusted closely to the wheel with a maximum opening of oneeighth inch to prevent the work from being jammed between the wheel and the rest, which may cause wheel breakage?

  Yes

  No

  N/A

• Is the abrasive wheel tongue guard adjusted so as the distance between the wheel periphery (face of the wheel) and the adjustable tongue does not exceed onefourth inch?

  Yes

  No

  N/A

• Is machinery that is designed for a fixed location anchored to prevent walking or moving?

  Yes

  No

  N/A

• Are machines guarded to protect the operator and other employees in the machine area from hazards such as those created by point of operation, ingoing nip points, rotating parts, flying chips and sparks?

  Yes

  No

  N/A

Welding Safety

• Are staff appropriately trained and inducted in the dangers of performing welding tasks?

  Yes

  No

  N/A

• Are students appropriately supervised by a competent person when welding?

  Yes

  No

  N/A

• are welding operators provided with the appropriate PPE?

  Yes

  No

  N/A

• Is there adequate ventilation for welding tasks?

  Yes

  No

  N/A

• Are there appropriate warning signs in welding areas?

  Yes

  No

  N/A

• Are welding screens used when performing welding tasks?

  Yes

  No

  N/A

• Are ventilation systems working adequately?

  Yes

  No

  N/A

• Workplace Incident Report

SECTION I

• Date and time of incident

  Date

• Date and time incident was reported.

  Date

• To whom was the incident reported?

• Location of incident. (Specify site location)

• Supervisor's Name

• Supervisor's Phone Number

• Was there any witness(es)? If yes, provide name(s).

  Yes

  No

  N/A
PERSON(S) INVOLOVED

• Name (Person 1):

• Phone:

• Sex:

  Male

  Female

• Age;

• Job Title:

• Time on job: (Yrs & Mos)

• Job Status:

  Full-time

  Part-time

  Temporary

  Seasonal

• Classification:

  Select First-Aid only Medical Near miss Lost time OH&S Reportable None

  • First-Aid only
  • Medical
  • Near miss
  • Lost time
  • OH&S Reportable
  • None

• Employee Disposition Status:

  Returned to Work

  Modified Duties

  Sent Home

  To Doctor

  To Hospital

• Medication prescribed? If yes list medications.

  Yes

  No

  N/A

NATURE OF INJURY

• Describe injury.

• Detail any first-aid or medical treatment administered. (Provide names)

• Property Damage:

  None

  Minor

  Serious

  Major

• Photo of damage.

  Media

• Property Damage:

  N/a

  Vehicle

  Equipment

  Private Property

• Photo of damage.

  Media

• Estimated cost of damage:

• Vehicle ID:

• Make/Model:

• Age:

• Equipment ID:

• Model:

• Age:

• Detailed description of incident. (Include environmental conditions at time of incident)

• Environmental photo:

  Media

• Environmental photo:

  Media

• Immediate (Direct Causes):

• Direct cause photo:

  Media

• Direct cause photo:

  Media

• Contributing (underlying) Factors:

• Contributing factors photo:

  Media

• Corrective Action (Include detail description of action and person(s) responsible for actions)

• What was the potential for severity?

  Minor

  Serious

  Major

• What could have potentially happened?

• What is the probability of reoccurrance?

  Remote

  Improbable

  Probable

• Signature

  Sign

• Fall Protection Assessment

• Is fall protection provided for elevations greater than 4 feet (industrial) or 6 feet (construction)?

  Yes

  No

  N/A

Working Platforms Surfaces

• Guardrail is sound and will withstand 200 lbs. in any direction at top-rail. Guardrail contains mid-rail that is midway between walking surface and top of guardrail?

  Not Applicable

  Non Compliant

  Insufficent

  Acceptable

  Excellent

• Guardrail is 42 inches high, 45 inches max at top edge?

  Not Applicable

  Non Compliant

  Insufficent

  Acceptable

  Excellent

• Is every hole in which a worker could fall protected by a cover or guard rail?

  Yes

  No

  N/A

• Was scaffolding constructed by a competent person and passed the scaffolding inspection checklist?

  Yes

  No

  N/A

• Yes

  No

  N/A

Anchor systems

• Was the anchor system designed, installed, inspected and used under supervision of qualified person, as part of a fall protection system that maintains a safety factor of at least 2?

  Yes

  No

  N/A

• Are each employee's anchors capable of supporting at least 5,000 lbs (22 kN)

  Media

• Are anchorages used to attach to personal fall protection equipment indedependent of any anchorage used to suspend employees or platforms on which they work?

  Media

Worker Training and Comptetency

• Workers demonstrate understanding of the 100% tie-off procedure.

  Not Applicable

  Non Compliant

  Insufficent

  Acceptable

  Excellent

• Workers are using fall arrest system correctly.

  Not Applicable

  Non Compliant

  Insufficent

  Acceptable

  Excellent

• Fall arrest equipment is in good condition.

  Not Applicable

  Non Compliant

  Insufficent

  Acceptable

  Excellent

Personal Fall Arrest Systems

• Are life lines made of synthetic fiber rope and free of cuts, abrasions, melted spots or other damage?

  Yes

  No

  N/A

• Are lifelines and travel restraint lines capable of supporting 5,000 load (22.2kN)?

  Yes

  No

  N/A

• Are personal fall protection systems used exclusively for employee fall protection and not any other purpose?

  Yes

  No

  N/A