Safety Rounding Form

• Conducted on

  Date

• Prepared by

• Name of Observer

  Select Patrice Sabatano Will Russell James Lundin Kathleen Kimble Michael Oyugi Gloria Lynn-Burnett Artis Baldwin Lucius Baldwin

  • Patrice Sabatano
  • Will Russell
  • James Lundin
  • Kathleen Kimble
  • Michael Oyugi
  • Gloria Lynn-Burnett
  • Artis Baldwin
  • Lucius Baldwin

• Date and Time of Safety Walk

  Date

• Building Observed?

  Select A Building B Building

  • A Building
  • B Building

• Floor Observed?

  Select P2 P1 1st 2nd 3rd 4th 5th 6th

  • P2
  • P1
  • 1st
  • 2nd
  • 3rd
  • 4th
  • 5th
  • 6th

• Number of employees Contacted?

  Select 1 2 3 4 5 6 7

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7

• Time Spent

  Select 5 minutes 10 minutes 15 minutes 20 minutes 25 minutes 30 minutes

  • 5 minutes
  • 10 minutes
  • 15 minutes
  • 20 minutes
  • 25 minutes
  • 30 minutes

Proper Personal Protective Equipment Needed for Job Task is Present?

• Apron/Coat

  Yes

  No

  N/A

• Goggles

  Yes

  No

  N/A

• Cut Resistant Gloves

  Yes

  No

  N/A

• Oven Mitt

  Yes

  No

  N/A

• Latex or Nitrile Gloves

  Yes

  No

  N/A

• Slip Resistant Shoes

  Yes

  No

  N/A

• Clean Complete Uniform

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

Training of Job Task Being Observed

• Training Provided

  Yes

  No

  N/A

• Training Adequate for task

  Yes

  No

  N/A

• Training is Current

  Yes

  No

  N/A

• Training is Understood

  Yes

  No

  N/A

Status of Tools and Equipment

• Tools and Equipment needed available?

  Yes

  No

  N/A

• Tools and Equipment is correct for the job at hand?

  Yes

  No

  N/A

• Tools and Equipment is in good condition?

  Yes

  No

  N/A

• Tools and Equipment is stored correctly?

  Yes

  No

  N/A

• Tools and Equipment is used correctly?

  Yes

  No

  N/A

Standards and Procedures

• Standards and Procedures are available?

  Yes

  No

  N/A

• Standards and Procedures are adequate?

  Yes

  No

  N/A

• Standards and Procedures are known?

  Yes

  No

  N/A

• Standards and Procedures are understood?

  Yes

  No

  N/A

• Standards and Procedures are followed?

  Yes

  No

  N/A

Housekeeping

• Caution Signage is available?

  Yes

  No

  N/A

• Closet is clean?

  Yes

  No

  N/A

• Closet is orderly?

  Yes

  No

  N/A

Environmental Hazards

• Does the floor have a slip hazard? (ie. food, grease, ice, wet, other)

  Safe

  At Risk

  N/A

• Are their any trip hazards in walkways? (ie. boxes, cords, uneven surfaces, ect.)

  Safe

  At Risk

  N/A

• Is there a hazard present that could cause a fall? (ie. broken ladder, not using handrail, unsafe aerial lift procedures, ect.)

  Safe

  At Risk

  N/A

• Is there a food safety hazard present? (ie. cross contamination, temps incorrect, improper glove use, food allergen deficiency, ect.)

  Safe

  At Risk

  N/A

• Are there any struck by/against hazards present? (ie. falling objects, moving objects, protruding objects in walkway, ect.)

  Safe

  At Risk

  N/A

• Are there any exposure hazards present? (ie. exposure to chemicals, electrical, loud noise, temperature, ect.)

  Safe

  At Risk

  N/A

• Is a strain/sprain hazard present? (ie. pulling instead of pushing, twisting instead of pivoting, unsafe lifting, ect.)

  Safe

  At Risk

  N/A

• Is there a cut or puncture hazard present? (ie. glass, improper knife storage, sharp edges, ect.)

  Safe

  At Risk

  N/A

Safe Comments

Unsafe Comments

Corrective Actions