SafeWorks Report

• Conducted on

  Date

• Prepared by

• Location

  Shell Fabrication

  Rubber Processing

  Main Assembly

  Primary Packaging

  Secondary Packaging

• Name of Associate

Shift:

• Frist

  Second

PPE

• Is Personal Protective Equipment (PPE) being worn in all areas where it is required?

  Yes

  No

  N/A

• Gloves

  Yes

  No

  N/A

• Ear Plugs

  Yes

  No

  N/A

• Safety Shoes/ Vest

  Yes

  No

  N/A

• Glasses/Goggles

  Yes

  No

  N/A

Machine Safety

• Is machine guarding in place?

  Yes

  No

  N/A

• List the machines that need guarding repairs

• Are LOTO procedures in place?

  Yes

  No

  N/A

• List the machines that need LOTO procedures replaced

  Yes

  No

  N/A

• Are you aware of any other safety related issue with equipment?

Ergonomics

• Were ergo stretches performed?

  Yes

  No

  N/A

• Are you aware of any ergonomic related issues?

  Yes

  No

  N/A

• Are Emergency Exits Clear?

  Yes

  No

  N/A

• Are there any blocked fire extinguishers?

  Yes

  No

  N/A

• Are sharps containers present?

  Yes

  No

  N/A

• Are sharps containers full

  Yes

  No

  N/A

• Are the floors slippery

  Yes

  No

  N/A

• What area has slippery floors

• Are Slip, Trip, Falls Hazards present?

  Yes

  No

  N/A

• List specific areas where slips/trips/fall hazards are present

• Are First aid kits available and sealed?

  Yes

  No

  N/A

• Report any Good Saves discovered during the shift

• Additional Safety Comments/Concerns

• Yes

  No

  N/A