Information

Safety and Health Assessment Program Evaluation (SHAPE)

Company Name

Type of Visit

Status

Retro Group

  • 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

  • Notes:

Accident Prevention Plan

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

  • Notes:

SAFETY Committee/Meetings

  • Is there an established Safety Committee?

  • Is there established weekly safety meeting?

  • Notes:

Weekly Inspections (construction)

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

  • Notes

OSHA 300 LOG

  • Does company keep an OSHA 300 LOG

  • Notes:

PERSONAL PROTECTIVE EQUIPMENT

  • Has a hazard assessment been conducted?

  • Is there an effective written PPE Program?

  • Are the employees trained?

  • Notes:

LOCK OUT/ TAG OUT

  • Is there a written LO/TO Program

  • Are the employees trained?

  • Notes:

First-Aid and CPR

  • Are First-Aid kits available on every job?

  • Are employees FIRST AID/CPR Trained?

  • Notes

Hazard Communication Program

  • Is there a written HAZCOM Program?

  • Are employees trained?

  • Is training documented?

  • Is there an MSDS

  • Do employees have reasonable access?

  • Notes

Hearing Conservation

  • Is there a written hearing conservation plan?

  • Are employees trained?

  • Notes:

Permit Required Confined Space Program

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

  • Is there a Written Confined Space Program?

  • Are employees trained?

  • Notes:

Respiratory Protection

  • Has the employer conducted a Hazard Assesement?

  • Is there a written Respirator Protection Program?

  • Are employees trained in the RPP?

  • Notes

Fall Protection

  • Has employer conducted a hazard assesement?

  • Is there a Written Fall Protection Plan?

  • Are employees trained?

  • Notes:

Hot Work

  • Does company have a Hot Work program established?

  • Are employees trained?

  • Notes:

MISC TOPICS

  • Does company conduct new hire orientation?

  • Does company have an employee discipline program?

Comments

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.