Proforma Safety Compliance Audit

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Which Branch is currently being audited?

  Select La Porte Texas City Lake Charles Beaumont Corpus Christi Corporate Office

  • La Porte
  • Texas City
  • Lake Charles
  • Beaumont
  • Corpus Christi
  • Corporate Office
• Location
  Address

• Personnel

• Branch Manager

OSHA poster displayed

• Verify OSHA poster

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

State and Federal Posters Displayed

• Verify State and Federal posters

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Minimum Wage Poster

OSHA 300 Logs

• Verify OSHA 300-A displayed (Feb 1 to Apr 30 only)

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify OSHA 300 Log current

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

OSHA 300 Log (Previous and current-to-date)

• Is the previous year’s log available

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Is this year's log up to date

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Accident Investigation Files

• Are files current

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Are they maintained

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify Incident log current

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Are Incident Investigation Reports completed in a timely manner

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Are Safety flashes completed and issued for all incident reports in a timely manner

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Monthly Facility Safety Audit Records

• Have audits been conducted at least monthly

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Have deficiencies been addressed

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Monthly Field Supervisor Site Hazard Audit Records

• Have Supervisor Hazard audits been conducted at least monthly

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Have deficiencies been addressed

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Job Safety Analysis Forms

• Are they completed properly

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Are they audited regularly

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify JSA's are retained for at least 1 year

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

H&S Manual Available & up-to-date

• Verify safety manual is available and updated as appropriate

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Safety Meeting Records

• Weekly topics and attendance records are maintained

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Monthly Safety meetings recorded and maintained

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Monthly supervisor safety meeting recorded and maintained

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Variance Files

• Variance files maintained and up-to-date

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Corporate Safety Reporting

• Do Monthly Safety reports get submit on time

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Does the meet monthly safety goals

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Does the Conduct Monthly Supervisor Safety Meetings

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Does the Conduct Monthly Branch Safety Meetings

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Does the conduct Weekly Safety Meetings (nested sited)

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Safety Incentive

• Does the maintain a Safety bucks log

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Does the offer any other safety incentives

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Employee Safety Evaluation Cards

• Does the maintain a record of card completion

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Is the higher than 50% completion of cards

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Job Safety Observations

• Verify JSO's are completed by (Managers)

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify JSO's are completed by (Supervisors)

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify JSO's are completed by (Safety)

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify JSO's are completed by (Employees)

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Job Safety Observation Log

• Verify JSO log's are maintained (Monthly)

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Training Files

• Is there a training file for all active employees

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify copies of training certificates filed with employee training records

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Completed training records up-to-date

• Verify new-hire training

  Yes

  No

  N/A

• Verify hands on training (if applicable)

  Yes

  No

  N/A

• Verify craft training (if applicable)

  Yes

  No

  N/A

Employee Required training Complete

• Verify required training by training matrix

  Yes

  No

  N/A

• Verify required safety refresher training

  Yes

  No

  N/A

• Verify required craft refresher training (if applicable)

  Yes

  No

  N/A

• Verify Shop Mechanics are Confined Space Trained

  Yes

  No

  N/A

• Verify Shop Mechanics are LOTO Trained (Authorized)

  Yes

  No

  N/A

• Verify all field employees are LOTO Trained (Affected)

  Yes

  No

  N/A

• Verify all field employees have current Pulmonary Function Test

  Yes

  No

  N/A

• Verify all field employees have current Fit Test (Scott AV-2000)

  Yes

  No

  N/A

• Verify all field employees have current Fit Test (3M 7800)

  Yes

  No

  N/A

• Verify all field employees have current Fit Test (3M 5K/6K)

  Yes

  No

  N/A

• Verify all field employees have current Audiogram (Annually)

  Yes

  No

  N/A

• Verify all field employees have current Supplied Air Training

  Yes

  No

  N/A

• Verify all field employees have current Basic Plus

  Yes

  No

  N/A

• Verify all field employees have current Evergreen New Employee Orientation

  Yes

  No

  N/A

• Verify all field employees have current Evergreen Hydro blast & Vacuum Training

  Yes

  No

  N/A

• Verify all field employees have current Hazwoper Training

  Yes

  No

  N/A

• Verify all field employee have fire protection training

  Yes

  No

  N/A

• Verify all field employees have been trained on safe use of fire extinguishers

  Yes

  No

  N/A

• Verify office personnel have fire protection training

  Yes

  No

  N/A

• Verify office personnel have been trained of safe use of fire extinguishers

  Yes

  No

  N/A

Training File by Topic Maintained

• Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Are training files kept with original attendance sheets filed by topic

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Corporate Training Programs Implemented

• Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Are corporate training programs being used

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Does the Branch have a Certified New Hire Trainer

  Yes

  No

  N/A

• Does the Branch have a Certified Hydro Blast Trainer

  Yes

  No

  N/A

• Does the Branch have a Certified Driver Trainer

  Yes

  No

  N/A

• Does the Branch have a Certified Hazwoper Trainer

  Yes

  No

  N/A

• Does the Branch have a Certified Forklift Trainer

  Yes

  No

  N/A

Driver Fatigue

• Verify drivers log Hours of Service

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify drivers logs audited

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Driver Qualifications

• Verify all drivers of CMV's have current Driver Qualification files

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify DQ files current

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify all drivers of CMV's have current D.O.T Physical Card

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify all drivers of CMV's have current Driver Test

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify all drivers of CMV's have current Smith Driver Training

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Equipment Files

• Does each piece of Equipment assigned to the Branch have an equipment file

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Are files formatted properly

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Are equipment info sheets completed on all equipment

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify all equipment has Gross Vehicle Weight (GVW)

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Pre-Trip/DVIR's

• Are pre trips maintained for previous 90 days

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Are work orders completed for pre-trips discrepancies

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify pre-trips and Work Orders filed in Equipment Files

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Equipment Inspections

• Have 25% of assets been inspected

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Equipment Maintenance

• Verify maintenance records backed up on Fleet Mentor

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify equipment maintenance schedule in place and records current

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Site Emergency Action Plan Complete

• Verify off site muster locations identified

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify on site muster locations identified

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Are quarterly drills conducted and documented

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Emergency Action Plan in place and employees trained

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Evacuation Routes Posted

• Verify evacuation routes are visibly posted

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Exits

• Verify exit signs are visible all lighted exit signs are lit

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify interior of exits are not blocked

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify exterior of exits are not blocked

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify exit doors are not locked

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Doors that are not exits marked "Not A Exit"

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Isles not cluttered

• Verify that isle ways do not have boxes and other clutter impeding walkways

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Lighting adequate

• Verify interior lighting is ok in offices and shop areas

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Emergency lighting provided if employees work at night or in a windowless building

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Site Hazard Communication Plan

• Verify the site specific information in the Hazard Communication Program is complete

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Containers/labels/tags

• Verify original containers and labels are marked with name of contents, hazard and manufacturer

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify secondary containers are marked with contents of container

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify containers are in good condition

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Chemicals and Waste Properly Stored

• Verify chemicals, diesel fuel, oils and hydraulic fluids are properly stored

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify wastes are marked and stored properly

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify proper containment area is used

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify area is not cluttered with trash or items not belonging in area

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Combustible materials properly stored

• Verify combustibles such as oily rags, flammable chemicals, diesel fuel and other materials are not being left sitting around or being stored improperly

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify area is not cluttered with trash or items not belonging in area

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Spill Kits Available for Clean-up

• Verify spill kits are available for clean-up

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Fire Extinguisher Locations Marked

• Verify fire extinguisher locations are properly marked and visible

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify fire extinguishers are charged and have current fire Marshall annual inspections

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Fire Extinguisher Inspections up-to-date

• Verify extinguishers are being inspected regularly (monthly)

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Fire Extinguishers Stored in Proper Locations

• Verify are in correct locations and accessible

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

No Smoking Signs Posted

• Verify “No Smoking Signs” are posted in all applicable areas

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

All Areas Free From Fire Hazards

• Verify fire hazards are not present

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Housekeeping

• Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• General area is free from clutter

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Trash cans not overflowing

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Workstations clean

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Unused tools in their proper place

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Floor free from spills and trip hazards

• Verify shop floor is free from chemical, oil, diesel or transmission fluid spills

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify there are no trip hazards caused by extension cords, wiring, flooring, boxes, parts or other material

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Lighting and ventilation adequate

• Verify lighting in office area is adequate

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify lighting in shop area is adequate

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify lighting in storage area is adequate

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify ventilation in chemical storage area is adequate

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify ventilation in welding area is adequate

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Machine guards in place and operable

• All machine guards are in place and being used

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

All Applicable Warning Signs in Place

• Verify hearing protection, goggles required, safety glasses required and other warning signs are in place as appropriate

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Bathroom, kitchen and break areas clean

• Verify bathrooms are clean and not being used for chemical storage

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify kitchens are clean and not being used to store chemicals or lab samples

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify refrigerators are being used for Food Only.

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify break areas are clean

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Stairways and/or landings properly guarded

• Verify steps and stairway have hand rails

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify landings have hand rails, mid-rails and toe-boards as appropriate

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

GFCI's

• GFCI’s are available and being used

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Operator certified

• Verify forklift operators have a valid certification and is not expired

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Equipment is being used as designed.

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Deficiencies noted during inspections are being corrected when noted.

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Equipment is in good condition.

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Seat belts available and used

• Verify forklifts are equipped with seatbelts and they are being used

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Fire extinguisher

• Verify a fire extinguisher is on-board fork lift

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Daily checklist completed

• Verify the daily check is complete and safety items addressed

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Files maintained and up-to-date

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Warning signs posted

• Verify Forklift warning signs are posted in activity areas

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Back-up alarms are operable.

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Perimeter fence in good condition

• Verify fence is in good condition

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Gate in good condition

• Verify gate is in good condition

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Area free from trip hazards

• Verify parking areas are free from trip hazards

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

No unmarked containers in area

• Verify there are no unknown packages or containers in area

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify there are no chemical drums in area

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Equipment parked in orderly manner

• Verify equipment and vehicles are parked in designated areas

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify parking areas are free from trip hazards

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

HOSE TESTING

• Hose testing done quarterly

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Hoses marked with color codes

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Hose testing done monthly

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Quarterly files being kept

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Are high pressure fittings marked correctly

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Fall Protection

• Does the Branch maintain fall protection properly

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify fall protection not soiled or damaged

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Are harness's and Lanyards of the same manufacturer

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Are harness and lanyards inspected quarterly (Competent Person)

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Are harness and Lanyards inspected monthly (Visual)

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify fall protection within life cycle

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

PPE

• Verify employees PPE in good overall condition

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify employees wearing Z87 eyewear

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify hardhat are within life cycle

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Body Protection

• FRC clothing in good overall condition.

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Holes in FRC clothing is not larger that a quarter.

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• FRC Clothing is not excessively soiled w/ oils or paint

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• FRC Clothing is worn with the zipper up.

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify employees in compliance with company uniform policy

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Ladder Condition is Ok

• Verify the ladder is in good condition. No missing or damage wrung's, steps or feet.

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Extension Cords

• Used properly

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• In good condition

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify extension cords are inspected and tested quarterly

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Power Tools

• Verify power tools are inspected monthly

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify that all hand power tools are in compliance with the Hand & Power Tool Safety Program

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify Bench grinders not to exceed 1/4" gap from wheel to adjustable tongue

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Appropriate PPE Storage Area

• Verify storage of PPE is acceptable

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Verify access to PPE is controlled

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Respiratory Protection

• Are respirator stored properly

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Are respirators maintained by qualified individual

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Evidence on respirators being used that employees are not fit tested for

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Storage Rooms (office)

• Are supplies stored and maintained in an orderly condition

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Do employees use material handling devices or get help to move heavy objects

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Is a step stool or ladder available to reach high places

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Office Furniture

• Are desk, chairs, file cabinets, etc., in good condition?

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• File drawers do not open into hallway or walkway?

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• File cabinet drawers kept closed when not in use?

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• File cabinets secured to prevent tip-over when the two upper drawers are open?

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Proper stepping stools provided?

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Employees trained not to use chairs for stepping stool?

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Are desk chairs ergonomically sound & roll smoothly?

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Are sharp objects stored where they can’t fall or be handled accidentally?

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Employees instructed to call maintenance when file cabinets, heavy objects moved?

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Electrical

• Electrical power cords in good condition?

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Three-prong grounded type plugs on power cords to office equipment where required?

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Electrical wall receptacles properly covered?

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Are office employees instructed not to make electrical repairs on office equipment?

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Identification/marking of circuit breakers noted in circuit breaker panels?

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Aisles, Floors & Stairs

• Is there a clear aisle way of four feet for two-way traffic within a room or hallway?

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Are floors, aisle ways, stairways, and hallways adequately lighted.

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Are electrical or telephone outlets in the floor protected by arrangement of furniture of other means to minimize the tripping hazard?

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Are carpet edges secure? Curled carpet edges or tears repaired so as to eliminate the tripping hazard?

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Do ramps or inclines have non-slip surfaces?

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Unusual changes in the walking surface are marked?

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Are spills cleaned up as soon as possible? Wet floor signs provided for custodial staff?

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Handrails provided on stairways?

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

• Stair treads in good condition?

  Yes

  No

  N/A

• Corrective Actions

• Assigned to:

Ergonomics

• Were workstations observed ergonomically correct?

  Yes

  No

  N/A

• Corrective Actions

• Assigned to: