Title Page
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Conducted on
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Conducted by
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Department
General
Housekeeping & General Work Environment
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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)
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Specify work station(s)
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2. Access to and from work stations and work areas are a minimum of 24 inches, free of obstructions and constantly accessible?
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Specify work station(s)
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3. Work stations are free of trash accumulation, clean, tidy, well organized and free of trip hazards?
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4. Storage areas are clean, orderly and tidy?
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5. Are employees addressing housekeeping issues as they see them?
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6. Emergency routes and emergency doors are kept clear and fully accessible at ALL TIMES?
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7. Emergency equipment (Fire Extinguishers, eyewash stations etc) free from obstructions and are constantly accessible?
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Specify work station(s)
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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?)
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9. Material and equipment is stored in such a way that projections do not interfere with walkways?
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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?
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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.
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12. Are pallets and materials laying flat and stacked securely and neatly?
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13. Are pallets that are in use in good condition?
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Facility Security: Visitor Management
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1. Contractors & Visitors are signing in and out of facility as required per Visitor Management Procedure?
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Provide Name and Company of each
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2. Contractor & Visitor Badges worn as required per Visitor Management Procedure?
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Provide Name and Company of each
Behavior Based Safety
General EHS Rules
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1. Employees wearing ID Badges as required per EHS General Rules?
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Specific Area(s)
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Provide name(s) of non-compliant employee(s) in notes
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Are Red or Pink Badge employees operating equipment alone, with another Red or Pink Badge Employee or without supervision?
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Provide employee names
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2. Forklift Operators are wearing Forklift ID Badges & training is current?
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List employees not wearing Forklift ID Badges
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3. Are employees adhering to cell phone and earbud policy?
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Provides Names of employees
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4. Are proper lifting procedures being followed?
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5. Are employees using caution around machines?
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Personal Protective Equipment (PPE)
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1. Are employees wearing appropriate PPE?
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Specify lack of or inappropriate PPE
- Safety Glasses/Goggles
- Rx Safety Glasses/Over the Glasses Safety Glasses
- Face Shields
- Steel Toes
- Gloves
- Respiratory Protection
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Enter employee names
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2. Is PPE being worn correctly?
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Enter employee names
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3. Is PPE maintained in a sanitary condition and ready for use?
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Specify work station(s)
Docks
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1. Are dock plates secure and in working order?
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2. Are dock locks secure and in working order?
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3. Are dock lights secure and in working order?
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4. Are dock chains/barriers in place, secure and in working order?
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5. Are chock blocks present, secure and in working order?
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Electrical
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1. Disconnecting switches and circuit breakers are labeled to indicate their use or equipment served.
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2. Cables and/or flexible cords with exposed wiring, frayed or deteriorated insulation, splices or taps present in work area.
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3. Flexible cords are only used in continuous lengths without splice or tap.
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4. Strain reliefs are free of exposed wiring, frayed/deteriorated insulation, splices or taps.
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5. Electrical enclosures such as switches, receptacles, junction boxes, etc., equipped with tight-fitting covers or plates.
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6. Multiple plug adaptors (e.g., power strips) are not used.
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7. All extension cords are equipped with grounding conductor.
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8. Extension cords are being used as permanent powers sources.
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Tools, Equipment and Machines
Machinery & Equipment
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1. Fixed machines are anchored to prevent tipping or other movement.
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Specify work station(s)
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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.
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3. Safe guards are in use (light curtains, cage doors, mezzanine gates, machine guards, dock chains, LOTO if applicable etc.)?
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4. Moving chains and gears are properly guarded.
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5. A power shut-off switch is provided within reach of the operator’s position at each machine.
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8. Manually operated valves and switches controlling operation of equipment/machines are clearly identified and readily accessible.
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8. Emergency stop buttons are mushroom shaped, colored red and have a yellow collar legend plate labeled "EMERGENCY STOP".
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Specify work station(s)
Sign-off
Sign-off
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Auditor
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Plant Manager
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Plant EHS
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Additional Personnel
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Additional Personnel