Phillips Staffing Worksite Evaluation

• Client

• Date of Evaluation

  Date

• Date of last evaluation

  Date

• Prepared by

• Location/Address
  Address

• Review OSHA.Gov for inspection data and list below

Evaluation

• List department and shift times for which employees are assigned.

• Are there overtime hours being worked at this customer?

  Yes

  No

  N/A

• List any injuries at the customer at the past year including injury description and corrective actions identified.

• What Personal Protective Equipment (PPE) is required and what department?

• List any department(s) or employees are not permitted to work in and why?

• Is there any lifting involved? if so, what is the maximum weight lifted?

• Is there an increase in claim activity at this employer?

  Yes

  No

  N/A

• Are any employees performing duties that involve powered industrial trucks?

  Yes

  No

  N/A

• Has it been verified that the employees are certified and also trained at the customer site?

General Information

• Any past, present, or discontinued operations which involve exposure to chemicals. painting, or hazardous materials?

  Yes

  No

  N/A

• Any work performed under, on, or above water?

  Yes

  No

  N/A

• Any work performed underground or higher than 6 feet above ground level?

  Yes

  No

  N/A

• Is the applicant involved in any business other than specified in the description of operations?

  Yes

  No

  N/A

• Any employees under the age of 16?

  Yes

  No

  N/A

• Do employees travel out of state or out of the country?

  Yes

  No

  N/A

• What scope of travel?

• Any group travel, ride-share programs, or tool or vehicle allowances provided?

  Yes

  No

  N/A

• Does the radius of operations vehicles exceed 200 miles?

  Yes

  No

  N/A

• Yes

  No

  N/A

Building/General

• Required OSHA posters visible

  Yes

  No

  N/A

• Required MSDS sheets visible

  Yes

  No

  N/A

• Safety rules posted

  Yes

  No

  N/A

• Evacuation and Emergency plans posted

  Yes

  No

  N/A

• First Aid Kits in appropriate place and fully stocked?

  Yes

  No

  N/A

• Fire Extinguisher tags up to date

  Yes

  No

  N/A

• Hazardous liquids/materials labeled correctly

  Yes

  No

  N/A

• Hazardous liquids stored in a safe place

  Yes

  No

  N/A

• Proper disposal of hazardous materials

  Yes

  No

  N/A

• Materials in a safe place (stacked correctly, out of walkways)

  Yes

  No

  N/A

• Proper ventilation or refuse exhaust system

  Yes

  No

  N/A

• Floors/walkways clean and clearly marked

  Yes

  No

  N/A

• Proper lighting

  Yes

  No

  N/A

• Emergency exits clearly marked

  Yes

  No

  N/A

• All exits accessible (not obstructed)

  Yes

  No

  N/A

• All areas clean, washrooms included

  Yes

  No

  N/A

Employees

• Following safety rules

  Yes

  No

  N/A

• Wearing proper PPE

  Yes

  No

  N/A

• Practicing proper lifting techniques

  Yes

  No

  N/A

• No unsafe behavior observed

  Yes

  No

  N/A

IF Operating machinery

• Operators seem properly trained

  Yes

  No

  N/A

• Practicing lock out/tag out procedures

  Yes

  No

  N/A

• Forklift drivers certified by OSHA

  Yes

  No

  N/A

• Safety check performed on machinery prior to operation

  Yes

  No

  N/A

• Appropriate clearance for machinery

  Yes

  No

  N/A

• Not wearing loose clothing around machines

  Yes

  No

  N/A

• Not wearing jewelry while operating machinery

  Yes

  No

  N/A

Tools and Equipment

• Equipment safety check daily

  Yes

  No

  N/A

• Appropriate storage of tools and equipment

  Yes

  No

  N/A

• Equipment clean and in proper working condition

  Yes

  No

  N/A

• Machines guards in good condition

  Yes

  No

  N/A

• Room to comfortably operate machinery

  Yes

  No

  N/A

• No machinery left running unattended

  Yes

  No

  N/A

• Describe the safe acts observed and actions taken to encourage continued safe performance

• Describe any unsafe acts observed and immediate corrective actions to prevent reoccurrence

• Any additional observations of employees while touring the facility

• Overall, would you consider this a safe place for an employee to work? Why or why not?

Completion

• Completed by (Name and Signature)

  Sign

• Reviewed by Risk Management

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