Title Page

  • Conducted on

  • Conducted by

  • Department

General

Housekeeping & General Work Environment

  • 1. Walking-working surfaces are kept clean, orderly, and free of debris?<br>(Walking-working surfaces: any horizontal vertical surface on or through which a worker walks, works, or gains access to a work area or workplace location)

  • Specify work station(s)

  • 2. Access to and from work stations and work areas are a minimum of 24 inches, free of obstructions and constantly accessible?

  • Specify work station(s)

  • 3. Work stations are free of trash accumulation, clean, tidy, well organized and free of trip hazards?

  • Specify work station(s)

  • 4. Storage areas are clean, orderly and tidy?

  • Specify work station(s)

  • 5. Are employees addressing housekeeping issues as they see them?

  • Specify work station(s)

  • 6. Emergency routes and emergency doors are kept clear and fully accessible at ALL TIMES?

  • Specify work station(s)

  • 7. Emergency equipment (Fire Extinguishers, eyewash stations etc) free from obstructions and are constantly accessible?

  • Specify work station(s)

  • 8. Sufficient access and working space is provided and maintained around all electrical equipment to permit safe operations and maintenance?<br>(Clear space is maintained in front of electrical panels; minimum 3 feet in front, and at least the width of the panel, but not less than 2 ½ feet?)

  • Specify work station(s)

  • 9. Material and equipment is stored in such a way that projections do not interfere with walkways?

  • Specify work station(s)

  • 10. Aisles and walkways that pass near moving or operating machinery, welding operations and similar operations are arranged so employees are not subjected to potential hazards?

  • Specify work station(s)

  • 11. Fan blades are protected with a guard having openings no larger than l/2 inch when operating within 7 feet (2.1336 meters) of the floor or working level.

  • Specify work station(s)

  • 12. Are pallets and materials laying flat and stacked securely and neatly?

  • Specify work station(s)

  • 13. Are pallets that are in use in good condition?

  • Specify work station(s)

Facility Security: Visitor Management

  • 1. Contractors & Visitors are signing in and out of facility as required per Visitor Management Procedure?

  • Provide Name and Company of each

  • 2. Contractor & Visitor Badges worn as required per Visitor Management Procedure?

  • Provide Name and Company of each

Behavior Based Safety

General EHS Rules

  • 1. Employees wearing ID Badges as required per EHS General Rules?

  • Specific Area(s)

  • Provide name(s) of non-compliant employee(s) in notes

  • Are Red or Pink Badge employees operating equipment alone, with another Red or Pink Badge Employee or without supervision?

  • Provide employee names

  • 2. Forklift Operators are wearing Forklift ID Badges & training is current?

  • List employees not wearing Forklift ID Badges

  • 3. Are employees adhering to cell phone and earbud policy?

  • Provides Names of employees

  • 4. Are proper lifting procedures being followed?

  • Specify work station(s)

  • 5. Are employees using caution around machines?

  • Specify work station(s)

Personal Protective Equipment (PPE)

  • 1. Are employees wearing appropriate PPE?

  • Specify lack of or inappropriate PPE

  • Enter employee names

  • 2. Is PPE being worn correctly?

  • Enter employee names

  • 3. Is PPE maintained in a sanitary condition and ready for use?

  • Specify work station(s)

Docks

  • 1. Are dock plates secure and in working order?

  • Specify work station(s)

  • 2. Are dock locks secure and in working order?

  • Specify work station(s)

  • 3. Are dock lights secure and in working order?

  • Specify work station(s)

  • 4. Are dock chains/barriers in place, secure and in working order?

  • Specify work station(s)

  • 5. Are chock blocks present, secure and in working order?

  • Specify work station(s)

Electrical

  • 1. Disconnecting switches and circuit breakers are labeled to indicate their use or equipment served.

  • Specify work station(s)

  • 2. Cables and/or flexible cords with exposed wiring, frayed or deteriorated insulation, splices or taps present in work area.

  • Specify work station(s)

  • 3. Flexible cords are only used in continuous lengths without splice or tap.

  • Specify work station(s)

  • 4. Strain reliefs are free of exposed wiring, frayed/deteriorated insulation, splices or taps.

  • Specify work station(s)

  • 5. Electrical enclosures such as switches, receptacles, junction boxes, etc., equipped with tight-fitting covers or plates.

  • Specify work station(s)

  • 6. Multiple plug adaptors (e.g., power strips) are not used.

  • Specify work station(s)

  • 7. All extension cords are equipped with grounding conductor.

  • Specify work station(s)

  • 8. Extension cords are being used as permanent powers sources.

  • Specify work station(s)

Tools, Equipment and Machines

Machinery & Equipment

  • 1. Fixed machines are anchored to prevent tipping or other movement.

  • Specify work station(s)

  • 2. Operator and other workers in the machine area are protected from hazards created at the point of operation, ingoing nip points, rotating parts, flying chips, and sparks.

  • Specify work station(s)

  • 3. Safe guards are in use (light curtains, cage doors, mezzanine gates, machine guards, dock chains, LOTO if applicable etc.)?

  • Specify work station(s)

  • 4. Moving chains and gears are properly guarded.

  • Specify work station(s)

  • 5. A power shut-off switch is provided within reach of the operator’s position at each machine.

  • Specify work station(s)

  • 8. Manually operated valves and switches controlling operation of equipment/machines are clearly identified and readily accessible.

  • Specify work station(s)

  • 8. Emergency stop buttons are mushroom shaped, colored red and have a yellow collar legend plate labeled "EMERGENCY STOP".

  • Specify work station(s)

Sign-off

Sign-off

  • Auditor

  • Plant Manager

  • Plant EHS

  • Additional Personnel

  • Additional Personnel

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.