• Department / Area / Machine #

  • Document No.

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Departmental Inspections & Meetings

  • Weekly Safety meeting or safety talk performed by Supervisor or Lead

  • Housekeeping / safety inspection completed for previous month?


  • Housekeeping Pics

  • Cleanliness of floor?

  • Area free of trash?

  • Are there misc. items / parts placed in nooks, cranny's, cubby holes that looks like CLUTTER?

  • Personal belongings put away? (Coats, purses, lunch boxes, shoes, etc.)

  • Racks and shelves organized?

  • Racks and shelves are properly labeled?

  • Walkways and passages clear to walk?

  • Brooms, mops, etc... Stored correctly when not in use?

  • Desks, carts, tables, toolbox & counters clean?

  • Any excessive dust noticed? (Special enfaces on combustible dust)

  • Are cords and hoses out of aisles and walkways?

  • Empty pallets, crates, or boxes removed from area before they become "clutter"?

  • Any pallets or skids leaning on it's side or standing on end?

  • Area around trash cans, bins, dumpsters, scrap bins is clean?

  • Do carts, racks or shelves that have protruding objects that could injure someone?

  • Drains, sinks or drinking fountains clean and free of spills?

  • Pics of "Clutter" or poor Housekeeping.

(PPE) Personal Protective Equipment

  • PPE Pics

  • Employees wearing safety glasses at all times?

  • Employees wearing gloves when exposed to cuts, scrapes, burns or chemical hazards?

  • Arm/wrist protectors worn as required?

  • Employees wearing face shield during grinding, sanding or other operations when required?

  • Face shield or splash goggles worn during chemical operations? (Splash Hazard into eyes)

  • Hearing Protection worn properly by employees when required?

  • Condition of PPE? (Clean & sanitary condition)

  • PPE properly stored when not being used?


  • Electrical Pics

  • Breaker box cover / door is closed when not in use?

  • Electrical panels, Breaker boxes, Disconnect boxes unobstructed? ( 3 ft clearance)

  • Electrical panels and devices labeled and secured? (Panel covers have all screws in place)

  • Are GFCI outlets being used properly or needed in this area?

  • Cover plates or switch plates in place?

  • Extension cords in good condition?

  • Extension cords NOT used on a permanent basis?

  • Extension cords not used across aisle ways or walk ways.

  • A quick (random) inspection was performed.

Machinery & Machine Guarding

  • Machine Pics

  • Is the current guard(s) effective?

  • Type of guard(s)?

  • Is the Light curtain working properly?

  • Potential for employee to reach (Over, Under, Around, Through) the guard?

  • E-stop properly labeled (Emergency Shut-off)?

  • Pinch Points labeled?

  • Caution / Warning signs in place?

  • Are all gates, grates, fencing, pin guards, etc in place to prevent employee from entering a hazardous area or nip point.

  • Are moving parts guarded (chains, belts, shafts, rotating/reciprocating parts, pinch points, etc.)?

  • Are bench grinders secured to bench or table, or is pedestal secured to floor.

Hand and Power Tools

  • Tool Pics

  • Power or Pneumatic Tools free from damage (switches and guards)?

  • Cords or hoses free from holes, damage, frays or exposed wiring?

  • Cord plug is equipped with ground plug....electrical?

  • Hand tools free from damage ( handles, shaft, head, etc.)?

  • Safety guards in place? (Grinders, sanders, etc.)

  • Grinders have handles in place and free from damage?

  • A quick (random) inspection was performed.

( Crane/Hoist ) - Lifting Devices / Lifting Components

  • Properly stored when not in use?

  • Properly tagged or labeled?

  • Is tag / label legible?

  • Is Crane / Sling inspections being documented in log book?

  • A quick (random) inspection was performed.

Emergency / First Aid

  • Clear access to fire extinguishers?

  • Are fire extinguishers properly mounted?

  • Are fire extinguisher signs in place?

  • Fire extinguisher inspections current?

  • Access to Emergency fire exits?

  • Access to First Aid items / kit?

  • Emergency Pics

Eye Wash Station

  • Eye Wash Pics

  • Accessible or clear path?

  • Are adequate signs marking the location?

  • Clean (Free from dust, dirt or other debris)?

  • Expiration date ok or last inspection ok?

  • Continuous flow unit has adequate flow or water pressure?

  • Caps or covers in place when not in use?

  • A quick (random) inspection was performed.


  • Chemical Pics

  • All chemical containers labeled?

  • Are labels legible?

  • Chemical spill kits available near by?

  • Chemicals used and/or stored in an approved containers?

  • Aerosol cans have lids/caps in place when not in use?

  • Flammable materials stored properly in flammable proof cabinet? (Ie:Acetone, Paint, etc.)

  • Flammable drums properly grounded / bonded to prevent sparks during transferring process?

  • Waste or spent chemicals properly labeled and stored ready for pick-up?

  • Adequate number of fire extinguishers in place?

  • Are there items that have the potential to catch fire or possibility to cause a fire.


  • Are welding screens safely in place around welding work areas?

  • Are welding screens clean or free from excessive dust?

  • Are welding gas bottles secured to rack, cart or fixture to prevent it from falling?

  • Are caps in place on bottles not being used?

  • Hoses and/or cords free from defects?

  • Is a respirator, PAPR or Supplied air welding hood needed?

  • A quick (random) inspection was performed.

Ladders (Fixed or Portable)

  • Stored or secured correctly while not in use?

  • Ladders free from defects or damage?

  • Properly labeled or identified?

  • A quick (random) inspection was performed.

Walking & Working Surfaces

Slip, Trip & Fall

  • Elevated work levels (Over 4 feet high) have guardrails or railing at the proper height of 42" with mid-rail at approx 21"?

  • Are fall arrest (Harness, Lanyard, Clips, Hooks) inspected?

  • Last documented inspection date.

  • Any observed Slip Hazards?

  • Any observed Trip Hazards?

  • Any observed Fall Hazards?

  • Slip, Trip Hazard Pics

  • Spills or leaks?

  • Cords or hoses across aisle ways or walk ways?

  • Misc. items obstructing aisle ways?

  • Any holes in floor have been reported to Supervisor or Maintenance to be fixed?

Forklift Operators

  • Daily operator inspection card filled out?

  • Was operator wearing seatbelt?

  • Traveling at an appropriate speed?

  • Honking horn in appropriate locations? (Corners, blind spots, etc...)


Waste & Waste Reduction (Hazardous, Non-Haz, Universal)

  • Drums have lids and/or caps in place when not in use?

  • Waste drums properly labeled?

  • Waste drum storage area labeled?

  • Waste satellite accumulation areas properly labeled?

Pollution Prevention

  • BMP's include: Good Housekeeping, Preventive Maintenance, SOP's, Spill Prevention, Training, Inspections

  • Are BMP's (Best Management Practices) observed to prevent pollution?


  • Are good recycling practices taking place?

  • Are recycling containers labeled?

Water Conservation

  • Any leaks or drips noticed?

Energy Conservation

  • Are lights turned off when applicable? (ie: natural light is plentiful or motion sensors are used)

  • Excess machinery, electrical devices are unplugged breakers turned off when not being utilized?

Waste water

  • Any observations of unauthorized items being disposed of down the drain?

Storm Water

  • Storm water drain access is clear and free from debris?

Secondary Containment

  • Is secondary containment being used?

  • Free from cracks, holes, etc?

  • Describe the type of secondary containment.

Unsafe acts observed?

  • Unsafe Acts?

For this area/dept, How many accidents have occurred since the last assessment?

  • Clinic Visit Injuries

  • First Aid Only

  • Report Only (No clinic visit needed)

  • Property Damage

  • Near Misses

Are there Risk controls that have failed or need to be enhanced in order to prevent future injuries?

  • PPE (Besides Safety Glasses & Steel Toes)

  • Engineering Controls

  • Administrative Controls / Work Practice Controls

  • Communication Controls

  • Additional comments on control failures.


  • Overall review?

  • Supervisor or Lead signature

  • EHS Manager signature

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