PDQ- LCO/OccMed Assessment

• Department:

• Class Code:

• Class Title:

• Functional Title:

• Date of last JHA

  Date
• Location:
  Address

• Prepared by:

• Department Site Personnel

Loss Control Officer REQUIRED Section

• TRAINING NEEDS

• Arc Flash

• Asbestos

• Annual Training Required

  Yes

  No

• Asbestos O&M Safety

• Annual Training Required

• Back Safety

• Blood Borne Pathogens- BBP

• Annual Training Required

• Confined Space

• Defensive Driving

• Electrical Safety

• Fall Protection

• Formaldehyde

• Annual Training Required

  Yes

  No

• Forklift

• County Training Required- Upon Hiring and every 3 years (Safety Shoe Voucher)

• Hand and Power Tools

• Hazcom/ GHS

• Hearing Conservation

• Hearing Conservation Program Required

  Yes

  No

• Heat Stress

• Ladder Safety

• LOTO

• Machine Guarding

• NFPA 70E

• PPE

• Respiratory Protection

• Respiratory Protection Program Required

  Yes

  No

• Slips, Trips, and Fails

• TB

• Trenching and Excavation (OSHA 1926)

• Welding, Cutting, Brazing

• Other:

• PPE REQUIREMENTS

• Gloves

• Hard Hat

• Hearing Protection

• Safety Glasses

• Safety Glasses Voucher if prescription glasses are worn

• Safety Goggles

• Safety Shoes

• Puncture Resistant

  Yes

  No

• Safety Vest

• Arc Flash

• Harness (Fall Protection)

• Splash Apron

• Other:

SIGNATURES

• Participating Employee:

  Sign

• Participating Facilities Management LCO:

  Sign