Title Page
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Conducted on
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Prepared by
Office
Housekeeping
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Do you observe any of the following: pits full, tools not put away, hoses laying out, spills on the floor, garbage laying out, or anything that could create a hazard? If yes, please take a picture of the hazard and give a small description of the situation.
Slip, Trip and Fall Hazards
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Do you observe any of the following: standing water, ice, spills, floor damage, uneven surfaces, hoses not put away, damaged grating, broken pallets, working above 4' without fall protection, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Noise and Lighting
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Do you observe any of the following: excessive noise, inadequate lighting, bulbs burnt out, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Access/Egress and Congestion
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Do you observe any of the following: blocked pathways, limited movement in these pathways, equipment or any object making walkways dangerous, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Electrical
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Do you observe any of the following: exposed wiring, extension cords not used as permanent wiring, covers in place, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Chemical and Biological
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Do you observe any of the following: correct PPE available and being worn, PPE stored properly, chemical odors in the area, chemical spills, containers/buckets that are not labeled and closed, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Tools and Equipment
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Do you observe any of the following: defective or damaged shadow boards and equipment, shadow boards missing items, no storage available for tools, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Procedure
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Are both site and corporate procedures being followed in this area? If no, please take a picture of the hazard and give a small description of the situation.
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If you found anything that could present a potential hazard but doesn't fall under any of the questions above (ergonomics, machine guarding, etc), please describe the danger below and take a picture of the situation.
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Resin Plant
Housekeeping
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Do you observe any of the following: pits full, tools not put away, hoses laying out, spills on the floor, garbage laying out, or anything that could create a hazard? If yes, please take a picture of the hazard and give a small description of the situation.
Slip, Trip and Fall Hazards
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Do you observe any of the following: standing water, ice, spills, floor damage, uneven surfaces, hoses not put away, damaged grating, broken pallets, working above 4' without fall protection, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Noise and Lighting
-
Do you observe any of the following: excessive noise, inadequate lighting, bulbs burnt out, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Access/Egress and Congestion
-
Do you observe any of the following: blocked pathways, limited movement in these pathways, equipment or any object making walkways dangerous, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Electrical
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Do you observe any of the following: exposed wiring, extension cords not used as permanent wiring, covers in place, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Chemical and Biological
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Do you observe any of the following: correct PPE available and being worn, PPE stored properly, chemical odors in the area, chemical spills, containers/buckets that are not labeled and closed, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Tools and Equipment
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Do you observe any of the following: defective or damaged shadow boards and equipment, shadow boards missing items, no storage available for tools, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Procedures
-
Are both site and corporate procedures being followed in this area? If no, please take a picture of the hazard and give a small description of the situation.
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If you found anything that could present a potential hazard but doesn't fall under any of the questions above (ergonomics, machine guarding, etc), please describe the danger below and take a picture of the situation.
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Truck Bay/Loading Dock
Housekeeping
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Do you observe any of the following: pits full, tools not put away, hoses laying out, spills on the floor, garbage laying out, or anything that could create a hazard? If yes, please take a picture of the hazard and give a small description of the situation.
Slip, Trip and Fall Hazards
-
Do you observe any of the following: standing water, ice, spills, floor damage, uneven surfaces, hoses not put away, damaged grating, broken pallets, working above 4' without fall protection, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Noise and Lighting
-
Do you observe any of the following: excessive noise, inadequate lighting, bulbs burnt out, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Access/Egress and Congestion
-
Do you observe any of the following: blocked pathways, limited movement in these pathways, equipment or any object making walkways dangerous, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Electrical
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Do you observe any of the following: exposed wiring, extension cords not used as permanent wiring, covers in place, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Chemical and Biological
-
Do you observe any of the following: correct PPE available and being worn, PPE stored properly, chemical odors in the area, chemical spills, containers/buckets that are not labeled and closed, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Tools and Equipment
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Do you observe any of the following: defective or damaged shadow boards and equipment, shadow boards missing items, no storage available for tools, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Procedure
-
Are both site and corporate procedures being followed in this area? If no, please take a picture of the hazard and give a small description of the situation.
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If you found anything that could present a potential hazard but doesn't fall under any of the questions above (ergonomics, machine guarding, etc), please describe the danger below and take a picture of the situation.
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Add media
Maintenance/Utility
Housekeeping
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Do you observe any of the following: pits full, tools not put away, hoses laying out, spills on the floor, garbage laying out, or anything that could create a hazard? If yes, please take a picture of the hazard and give a small description of the situation.
Slip, Trip and Fall Hazards
-
Do you observe any of the following: standing water, ice, spills, floor damage, uneven surfaces, hoses not put away, damaged grating, broken pallets, working above 4' without fall protection, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Noise and Lighting
-
Do you observe any of the following: excessive noise, inadequate lighting, bulbs burnt out, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Access/Egress and Congestion
-
Do you observe any of the following: blocked pathways, limited movement in these pathways, equipment or any object making walkways dangerous, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Electrical
-
Do you observe any of the following: exposed wiring, extension cords not used as permanent wiring, covers in place, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Chemical and Biological
-
Do you observe any of the following: correct PPE available and being worn, PPE stored properly, chemical odors in the area, chemical spills, containers/buckets that are not labeled and closed, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Tools and Equipment
-
Do you observe any of the following: defective or damaged shadow boards and equipment, shadow boards missing items, no storage available for tools, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Procedure
-
Are both site and corporate procedures being followed in this area? If no, please take a picture of the hazard and give a small description of the situation.
-
If you found anything that could present a potential hazard but doesn't fall under any of the questions above (ergonomics, machine guarding, etc), please describe the danger below and take a picture of the situation.
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Add media
Formaldehyde Plant
Housekeeping
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Do you observe any of the following: pits full, tools not put away, hoses laying out, spills on the floor, garbage laying out, or anything that could create a hazard? If yes, please take a picture of the hazard and give a small description of the situation.
Slip, Trip and Fall Hazards
-
Do you observe any of the following: standing water, ice, spills, floor damage, uneven surfaces, hoses not put away, damaged grating, broken pallets, working above 4' without fall protection, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Noise and Lighting
-
Do you observe any of the following: excessive noise, inadequate lighting, bulbs burnt out, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Access/Egress and Congestion
-
Do you observe any of the following: blocked pathways, limited movement in these pathways, equipment or any object making walkways dangerous, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Electrical
-
Do you observe any of the following: exposed wiring, extension cords not used as permanent wiring, covers in place, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Chemical and Biological
-
Do you observe any of the following: correct PPE available and being worn, PPE stored properly, chemical odors in the area, chemical spills, containers/buckets that are not labeled and closed, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Tools and Equipment
-
Do you observe any of the following: defective or damaged shadow boards and equipment, shadow boards missing items, no storage available for tools, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Procedures
-
Are both site and corporate procedures being followed in this area? If no, please take a picture of the hazard and give a small description of the situation.
-
If you found anything that could present a potential hazard but doesn't fall under any of the questions above (ergonomics, machine guarding, etc), please describe the danger below and take a picture of the situation.
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Add media
Tank Farm
Housekeeping
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Do you observe any of the following: pits full, tools not put away, hoses laying out, spills on the floor, garbage laying out, or anything that could create a hazard? If yes, please take a picture of the hazard and give a small description of the situation.
Slip, Trip and Fall Hazards
-
Do you observe any of the following: standing water, ice, spills, floor damage, uneven surfaces, hoses not put away, damaged grating, broken pallets, working above 4' without fall protection, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Noise and Lighting
-
Do you observe any of the following: excessive noise, inadequate lighting, bulbs burnt out, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Access/Egress and Congestion
-
Do you observe any of the following: blocked pathways, limited movement in these pathways, equipment or any object making walkways dangerous, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Electrical
-
Do you observe any of the following: exposed wiring, extension cords not used as permanent wiring, covers in place, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Chemical and Biological
-
Do you observe any of the following: correct PPE available and being worn, PPE stored properly, chemical odors in the area, chemical spills, containers/buckets that are not labeled and closed, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Tools and Equipment
-
Do you observe any of the following: defective or damaged shadow boards and equipment, shadow boards missing items, no storage available for tools, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Procedure
-
Are both site and corporate procedures being followed in this area? If no, please take a picture of the hazard and give a small description of the situation.
-
If you found anything that could present a potential hazard but doesn't fall under any of the questions above (ergonomics, machine guarding, etc), please describe the danger below and take a picture of the situation.
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Add media
Other Areas (specify in which area hazard was located in)
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Please specify where you are conducting this evaluation.
Housekeeping
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Do you observe any of the following: pits full, tools not put away, hoses laying out, spills on the floor, garbage laying out, or anything that could create a hazard? If yes, please take a picture of the hazard and give a small description of the situation.
Slip, Trip and Fall Hazards
-
Do you observe any of the following: standing water, ice, spills, floor damage, uneven surfaces, hoses not put away, damaged grating, broken pallets, working above 4' without fall protection, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Noise and Lighting
-
Do you observe any of the following: excessive noise, inadequate lighting, bulbs burnt out, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Access/Egress and Congestion
-
Do you observe any of the following: blocked pathways, limited movement in these pathways, equipment or any object making walkways dangerous, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Electrical
-
Do you observe any of the following: exposed wiring, extension cords not used as permanent wiring, covers in place, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Chemical and Biological
-
Do you observe any of the following: correct PPE available and being worn, PPE stored properly, chemical odors in the area, chemical spills, containers/buckets that are not labeled and closed, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Tools and Equipment
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Do you observe any of the following: defective or damaged shadow boards and equipment, shadow boards missing items, no storage available for tools, or anything that could create a hazard? If yes, please take a picture of the danger and give a small description of the situation.
Procedure
-
Are both site and corporate procedures being followed in this area? If no, please take a picture of the hazard and give a small description of the situation.
-
If you found anything that could present a potential hazard but doesn't fall under any of the questions above (ergonomics, machine guarding, etc), please describe the danger below and take a picture of the situation.
-
Add media
Signature
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Please sign below, save, and click the text box to type your name.
