Information

  • Client:

  • Conducted on:

  • Prepared by:

  • Client representative(s) present during assessment:

Business Information

  • Business operations:

  • Operations include commercial new construction.

  • Operations include commercial remodeling.

  • Operations include commercial service/repair.

  • Operations include residential new construction.

  • Operations include residential remodeling.

  • Operations include residential service/repair.

  • Equipment used by workers:

  • Other equipment used:

  • Equipment new and/or maintained?

  • Does the company use sub-contractors?

  • Certificates of insurance are obtained and verified.

  • Subcontractors are screened/pre-qualified for safety performance.

  • Subcontractors screening/pre-qualification efforts include:

  • Other subcontractor screening/pre-qualification efforts include:

  • Radius of operations

  • Out of state operations:

  • Ownership change in the past year?

  • Does this company have any secondary businesses?

Employee screening

  • How does the company find applicants?

  • Written applications required.

  • Applications and/or written job descriptions list the essential functions of the job (climbing ladders, lifting and carrying up to 75 pounds, crawling).

  • Criminal background checks conducted.

  • Criminal checks performed:

  • Workers compensation background checks conducted.

  • Work references veriied.

  • Integrity testing conducted.

  • Pre-hire drug testing is conducted.

  • Post-accident drug testing is conducted.

  • Suspicion drug testing is conducted.

  • Random drug testing is conducted. If yes, explain how many are tested how often.

  • DOT drug testing guidelines are followed for CDL holders.

  • Drug testing conducted per project contract, such as government projects.

  • Post-offer/pre-placement physicals performed.

  • MVR checks conducted.

Workforce

  • Total number of employees:

  • Number of unskilled laborers:

  • Number of skilled (foremen, carpenters, jouneymen) craft workers:

  • Number of full-time drivers:

  • Number of mechanics:

  • Number of office management and administration staff (sales, estimating, HR):

  • Number of contract (1099) workers:

  • Number of other workers (specify by job title):

  • Company utilizes temporary and/or day labor.

  • Labor is paid:

  • Percentage of shifts worked that exceed 10 hours per day:

  • Average annual turnover rate:

  • Percent of employees who's primary language is not English:

  • How are language barriers managed?

Employee Benefits

  • Is health insurance offered to emloyees?

  • How soon are health insurance benefits available to employees?

  • What percentage of premium does the company pay for the employee?

  • What percentage of workers participate in healthcare coverage?

  • Does the company offer a wellness program?

  • Does the company offer an Employee Assistance Program (EAP)?

Safety Coordinator

  • Designated safety coordinator in place with documented roles and responsibilities.

  • Percentage of time safety coordinator commits to safety.

  • Safety coordinator is in the field regularly to assess safety, correct unsafe conditions, assess/address needs for proper tools and PPE.

  • Safety coordinator is knowledgeable in field operations, hazard identification, applicable regulatory requirements, and applicable safety controls.

  • Safety coordinator has pursued professional development opportunities in the past year to improve technical expertise and effectiveness of safety efforts. If yes, list any training, seminars, or conferences attended.

  • Safety coordinator has identified loss trends using insurance carrier loss history reports or other loss data in the last year.

  • Written action plans based off of loss trends are developed and shared with management and/or safety committee for implementation.

  • Other comments regarding safety coordinator:

Safety Program - Safety Training

  • New Hire Safety Training

  • Weekly toolbox talks documented.

  • Daily safety huddles/task-hazard-analysis conducted.<br>

  • Daily safety huddles/task-hazard analysis are documented and signed by crew.

  • Routine company-wide safety meetings/training conducted:

  • OSHA 10-Hour training is provided.

  • OSHA 10-Hour training is provided to:

  • OSHA 30-Hour training is provided.

  • OSHA 30-Hour training is provided to:

  • Documented scaffold competent person training is provided.

  • Scaffold competent person training is provided to:

  • Documented fall protection competent training is provided.

  • Fall protecton training is provided to:

  • Documented excavation competent person training is provided.

  • Excavation competent person training is provided to:

  • First aid training is provided.

  • First aid training is provided to:

  • CPR training is provided.

  • CPR training is provided to:

  • Documented forklift training is provided to company-authorized forklift operators.

  • Other safety training is provided. If yes, list topics.

  • Other comments regarding safety training:

Safety Program - Enforcement of Safety Rules and Safe Working Conditions

  • Safety program includes a written safety rule enforcement policy.

  • Workplace safety inspections

  • Corrective actions are documented on inspection documents to verify completion.

  • Safety violations

Safety Program - Safety Rules

  • Safety rules are:

  • Rules are reviewed and updated annually. Rules are dated to confirm last review/revision.

  • Employees received training on rules updated over the past year.

  • Other comments regarding safety rules:

Safety Program - Claims Management

  • Formal claims management procedure in place.

  • Claims procedure is company-specific (lists designated medical providers, policy number, claim reporting instructions)

  • New hires are informed in writing of company's designated medical providers.

  • Injured workers are informed in writing of company's designated medical providers.

  • Other comments regarding claims management:

Accident Investigation

  • Accident investigations are documented.

  • Accidents are investigated by:

  • Investigations identify contributing factors.

  • Investigations identify root causes.

  • Findings have stimulated changes in training, tools, processes, safety rules, or enforcement in the past year. If yes, provide specific example.

  • Injured worker completes accident statement outlining event and injuries incurred.

  • Other comments regarding accident investigation.

Return-to-Work

  • Return-to-work implementation.

Evaluation Signature and Date

  • Evaluator's signature:

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.