Safety and Health Assessment Program Evaluation

Safety and Health Assessment Program Evaluation (SHAPE)

Company Name

Type of Visit

Status

• Select Complete Cancelled Rescheduled Follow-Up

  • Complete
  • Cancelled
  • Rescheduled
  • Follow-Up

Retro Group

• Select MBA-GRIP Individual Smart Dream Team Smart A Team Smart Advantage Smart Healthcare PITB PITB Platinum

  • MBA-GRIP
  • Individual
  • Smart Dream Team
  • Smart A Team
  • Smart Advantage
  • Smart Healthcare
  • PITB
  • PITB Platinum

• Safety Review Visit Conducted by:

Follow Up Scheduled:

• Follow up scheduled (if Applicable):

General Information

Number of Employees:

Contact Name

Email

WISHA POSTER

• WISHA Poster

  Yes

  No

  N/A

• Notes:

Accident Prevention Plan

• Is there an effective and practical ACCIDENT PREVENTION PLAN Present?

  Yes

  No

  N/A

• Notes:

SAFETY Committee/Meetings

• Is there an established Safety Committee?

  Yes

  No

  N/A

• Is there established weekly safety meeting?

  Yes

  No

  N/A

• Notes:

Weekly Inspections (construction)

• Is the company completing weekly "Walk around Inspections"? (construction)

  Yes

  No

  N/A

• Notes

OSHA 300 LOG

• Does company keep an OSHA 300 LOG

  Yes

  No

  N/A

• Notes:

PERSONAL PROTECTIVE EQUIPMENT

• Has a hazard assessment been conducted?

  Yes

  No

  N/A

• Is there an effective written PPE Program?

  Yes

  No

  N/A

• Are the employees trained?

  Yes

  No

  N/A

• Notes:

LOCK OUT/ TAG OUT

• Is there a written LO/TO Program

  Yes

  No

  N/A

• Are the employees trained?

  Yes

  No

  N/A

• Notes:

First-Aid and CPR

• Are First-Aid kits available on every job?

  Yes

  No

  N/A

• Are employees FIRST AID/CPR Trained?

  Yes

  No

  N/A

• Notes

Hazard Communication Program

• Is there a written HAZCOM Program?

  Yes

  No

  N/A

• Are employees trained?

  Yes

  No

  N/A

• Is training documented?

  Yes

  No

  N/A

• Is there an MSDS

  Yes

  No

  N/A

• Do employees have reasonable access?

  Yes

  No

  N/A

• Notes

Hearing Conservation

• Is there a written hearing conservation plan?

  Yes

  No

  N/A

• Are employees trained?

  Yes

  No

  N/A

• Notes:

Permit Required Confined Space Program

• Has the employer evaluated the workplace to determine if confined spaces are present?

  Yes

  No

  N/A

• Is there a Written Confined Space Program?

  Yes

  No

  N/A

• Are employees trained?

  Yes

  No

  N/A

• Notes:

Respiratory Protection

• Has the employer conducted a Hazard Assesement?

  Yes

  No

  N/A

• Is there a written Respirator Protection Program?

  Yes

  No

  N/A

• Are employees trained in the RPP?

  Yes

  No

  N/A

• Notes

Fall Protection

• Has employer conducted a hazard assesement?

  Yes

  No

  N/A

• Is there a Written Fall Protection Plan?

  Yes

  No

  N/A

• Are employees trained?

  Yes

  No

  N/A

• Notes:

Hot Work

• Does company have a Hot Work program established?

  Yes

  No

  N/A

• Are employees trained?

  Yes

  No

  N/A

• Notes:

MISC TOPICS

• Does company conduct new hire orientation?

  Yes

  No

  N/A

• Does company have an employee discipline program?

  Yes

  No

  N/A

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