Title Page

  • Department

  • Date

  • Prepared by

  • Location


  • Forklifts are operated only by trained & certified operators

  • All forklifts are operated in compliance with safety rules

  • Forklifts never drive with the load raised

  • Forklifts loads are never raised in the vicinity of people

  • There are no unguarded blades, chains, or pinch points

  • Grinders have properly adjusted tool (1/8") and toe (1/4") guards

  • All machine guards are in place and operating

  • All guards are checked by operators daily

  • The supervisor checks all guards at least weekly

  • All employees wear hearing protection where required

  • All employees are trained before operating machine

  • Jewelry and loose clothing is prohibited & long hair is contained

  • Employees practice Lockout/Tagout safety 100% of the time


  • Each machine has an electrical disconnect

  • All electrical panels and shutoffs are accessible

  • All plugs have a ground connection (except double insulated)

  • All machines are properly grounded

  • Extension cords are for temporary use only

  • All cords are in good condition (no frayed or exposed wires)


  • All employees support the safety program

  • All employees have received job specific safety training

  • Training is provided for new processes, procedures & equipment

  • The supervisor maintains documentation of safety training

  • The supervisor or lead attended both Supervisor SC meetings

  • A department employee attended both Employee SC meetings

  • Safety topics were discussed at both Safety Shutdowns

  • Identified hazards have been corrected or a work order generated

  • Lighting is adequate and working

  • All walking surfaces are in good condition


  • All injuries, illnesses, and incidents have been reported

  • Employees with injuries pain, or discomfort see the nurse

  • Employees are encouraged to report work related discomfort


  • PPE is issued to all who need it

  • PPE is stored correctly

  • PPE is maintained in good condition

  • PPE is appropriate for the hazard

  • Employees are trained to use all required PPE

  • The supervisor ensures that PPE is worn when needed

  • The supervisor has inspected all PPE each week

  • Employees who wear dust masks have received dust mask tng.


  • There is an MSDS in the binder for each chemical in your dept.

  • Chemicals are stored & handled safely

  • Chemicals are labeled as to contents

  • Employees are trained on the chemicals they use

  • Employees practice good personal hygiene

  • Small spills and leaks are promptly cleaned up

  • Maintenance is called for all medium to large spills

  • Safety showers and eyewash stations are flowed monthly

  • There is free access to safety showers and eyewash stations

  • Connection on drums & tanks are vapor & liquid tight


  • Chemical containers are completely emptied before disposal

  • Chemical waste containers are correctly labeled

  • All chemical waste containers are kept under cover

  • No wastes can enter the stormdrains

  • Spill containment materials are available for your area


  • Floors are swept up and kept clean

  • Aisles are free of obstructions at all times

  • Escape routes are clear at all times

  • Work areas are clean, neat, and organized

  • Outside work areas are clean, neat, & organized

  • Sawdust is kept cleaned up and not allowed to accumulate

  • Sawdust is vacuumed, not blown, to keep it from entering the air

  • No oil, grease, chemicals, or sawdust can flow into storm drains


  • Fire extinguishers are in place, checked monthly, & clear access

  • There are no accumulations of combustible materials

  • Fire doors and fire exits are never blocked

  • There is clear access to all fire equipment (Hydrants, risers, etc.)

  • Dirty and oily rags are stored in self-closing metal containers

  • Employees are aware of hazards and trained to work with them


  • The escape plan is posted in the area

  • All employees know where to go and how to get there

  • All employees know how to report emergencies

  • All exits are at least 30" wide

  • The first aid kit is stocked

  • Ladders, stools, etc. are in good condition with non-slip feet

  • Ladders are free of oil, grease, and dirt

  • Non-conducting ladders are used for electrical work

  • Employees are trained on the correct use of ladders

  • Employees never stand on the top steps of step ladders


  • All tools and handles are maintained in good condition

  • Tools with damage or mushroomed heads are repaired/replaced


  • Additional Comments

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