Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
Assessment
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Review this image before proceeding with your safety inspection
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Are floors free of water, ice, oil or other fluids?
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Are floor surfaces even (eg no loose tiles or carpet that is torn or has ridges or holes)?
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Is there a safety risk?
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Mark clearly on this map where the risk has been identified
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Supervisor has been automatically notified
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Are walkways and doorways clear of boxes, extension cords and litter?
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Are work areas, walkways and stairs well lit?
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Are all lights working?
Final comments
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Sign off
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Supervisor sign off
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Additional Comments - Is there anything else you would like us to know?
