Quarterly Review

• Store No.

• Conducted on

  Date

• Conducted By

• Location
  Address

• Manager

• Signature

  Sign

Service Area

• Are safety cages being used<br>

  Yes

  No

  N/A

• Has the trajectory zone been identified <br>

  Yes

  No

  N/A

• Are six foot whips being used<br>

  Yes

  No

  N/A

• Are Blue bars being used

  Yes

  No

  N/A

• Is the Golden Bar being used.

  Yes

  No

  N/A

• Ensure tire bars and other tools are in good working order<br>

  Yes

  No

  N/A

• Ensure weight is being removed after placement of jack stands and jack stands are placed properly

  Yes

  No

  N/A

• Ensure guards are not missing from machinery and equipment

  Yes

  No

  N/A

• Are all employees wearing proper PPE (Safety Glasses, Safety Shoes, Hearing protection (where required)

  Yes

  No

  N/A

• Has the shop equipment checklist been completed

  Yes

  No

  N/A

• Have torque guns been checked and roation of PM documented

  Yes

  No

  N/A

ForkLift

• Have employees operating forklifts been properly trained

  Yes

  No

  N/A

• Are forklift operators wearing seatbelts

  Yes

  No

  N/A

• Has the daily forklift inpection been completed

  Yes

  No

  N/A

Facility

• Has Fire Extinguishers been checked monthly

  Yes

  No

  N/A

• Ensure eye wash stations are available, in good working order, and being checked weekly (for fresh water stations) or monthly (for self-contained stations)

  Yes

  No

  N/A

• Ensure that chains/bars. are in place to prevent falls fron upstairs storage or loading docks (if present)

  Yes

  No

  N/A

• Ensure posters, labels, stickers or color codes are used to warn teammates of potential hazards.

  Yes

  No

  N/A

• Ensure that the store if free of slip/trip hazards (hoses, oil, tools)

  Yes

  No

  N/A

Training

• Did you ensure that all new hired teammates have completed the required safety training prior to starting work and that you have supporting documentation. This includes Safety Smart, TIA, Pre-Trip and Forklift

  Yes

  No

  N/A

• Did store complete quarterly safety training

  Yes

  No

  N/A

• Is all TIA training complete and up to date

  Yes

  No

  N/A

4 S

• Is the facility clean

  Yes

  No

  N/A

• Where is the store in the 4S process

  Yes

  No

  N/A

Vehicles

• Has the vehicle equipment check list been completed

  Yes

  No

  N/A

• Are pre-trips completed at the beginning of shift and turned in prior to going out on service call?

  Yes

  No

  N/A

• Has the manager signed off on any pre-trips inspections that indicated repairs were required

  Yes

  No

  N/A

Injuries

• Were all injuries reported within 24 to Medcor

  Yes

  No

  N/A

• Was a investigation of injury completed

  Yes

  No

  N/A

Safety Committee

• Has the location established a safety committee

  Yes

  No

  N/A

• Have activities been given to committee to perform

  Yes

  No

  N/A

• Has the committee performed there activities

  Yes

  No

  N/A

• Has the committe met monthly and presented there findings to manager. Documentation needed.

  Yes

  No

  N/A

OTHER

• Did you complete the Service Tech inspection Checklist as required by the compliance department.

  Yes

  No

  N/A

• Did you sign and post your OSHA 300A?

  Yes

  No

  N/A

• Did you ensure that all action items outlined by the Safety Coordinator were addressed and completed within 30 days unless otherwise noted.

  Yes

  No

  N/A

• Was a quarterly review held with your District Manager?

  Yes

  No

  N/A

COMMENTS

• Manager sign

  Sign