Snelling - Worksite Safety Evaluation

• Document No.

• Office Number

• Audit Title

• Conducted on

  Date

General Site Information

• Company Name Address City / State / Zip

• Phone Number

• Onsite Contact

• Nature of Operations

• SIC / NAICS

• Types of Injuries on Loss Report

• Number of Full Time Employees

• Number of Temporary Employees

• Departments Employees Work in

• Jobs Being Performed

Loss Review - Claim Cost

• Losses in 2011

• Losses in 2012

• Losses in 2013

• Losses in 2014

Types of Injuries

• List Top 5 Injuries and Number of Incidents

Highest Loss

• List Highest Loss Categories

Number of Injuries by Year

• 2011

• 2012

• 2013

• 2014

OSHA Information

• Are OSHA Logs Available for Last 5 Years?

  Yes

  No

  N/A

• Number of Injuries in Current Year

• Total Hours Worked in Current Year

• Temporary Employees Included on OSHA Log?

  Yes

  No

  N/A

• OSHA Inspections / Citations

  No

  Yes

DART Information

• Listed on Current Year DART Inspection List

  No

  Yes

• DART for Previous 2 Years

Safety Program Review

• Safety / Health Mission Statement

  Yes

  No

  N/A

• Written Safety Program

  Yes

  No

  N/A

• Review Safety Program

• Has Program Been Reviewed Within the Last 12 Months

  Yes

  No

  N/A

• Who is Responsible for Safety Program

• Does Facility Have a Safety Committee?

  Yes

  No

  N/A

• If yes.....Number of Members?

• Date of Last Meeting

• JHA's or JSA's Completed for Each Job?

  Yes

  No

  N/A

• Do Employees Receive Training on JSA or JHA's?

  Yes

  No

  N/A

• Does Facility Conduct Periodic Safety Audits?

  Yes

  No

  N/A

• Frequency of Audits?

• How are Corrective Actions Followed up on for Closure / Sustainability?

• Review Documentation

• Emergency Action Plan?

  Yes

  No

  N/A

• Date of Last Evacuation / Severe Weather Drill?

• PM Program for Equipment?

  Yes

  No

  N/A

• Equipment Specific Orientation / Training?

  Yes

  No

  N/A

• If Yes.......Designated Trainers

• Training Documented?

  Yes

  No

  N/A

• How are Changes Handled During the Shift?

• Do Lead, Supervisors and Managers Receive Safety Training?

  Yes

  No

  N/A

• Frequency

• Designated Trainer

• First aid / CPR Trained Personnel?

  Yes

  No

  N/A

• If yes.... How Many Trained per Shift?

• Pre-shift / Toolbox Meetings?

  Yes

  No

  N/A

• Frequency

• Training Documented?

  Yes

  No

  N/A

• Monthly Safety Meetings?

  Yes

  No

  N/A

• Topics Covered

• Training Documented?

  Yes

  No

  N/A

• Disciplinary / Corrective Action Policy for Safety Violations?

  Yes

  No

  N/A

• Safety Incentive / Observation Program?

  Yes

  No

  N/A

• Is incentive Program Based on Injures? (No Recordables, Injuries, etc)

  No

  Yes

• Reward

• Frequency of Reward

• Injury Illness Prevention Plan (CA Only)

  Yes

  No

  N/A

• Written Plan?

  Yes

  No

  N/A

• Reviewed Annually?

  Yes

  No

  N/A

• Date of Last Review

• Do Temporary Employees Receive Site Specific Orientation Prior to Starting Work?

  Yes

  No

  N/A

• Training Records Available?

  Yes

  No

  N/A

• If No.......When Do They Receive Training?

Specific Safety Program Review

• PPE Required

  Yes

  No

  N/A

• Eye / Face

  Yes

  No

  N/A

• Type Required

• Foot Protection

  Yes

  No

  N/A

• Type Required

• Hand Protection

  Yes

  No

  N/A

• Type Required

• Arm

  Yes

  No

  N/A

• Type Required

• Hearing Protection

  Yes

  No

  N/A

• Type Required

• Respiratory

  Yes

  No

  N/A

• Type Required

• Head

  Yes

  No

  N/A

• Type Required

• Body

  Yes

  No

  N/A

• Type Required

• Training completed for PPE?

  Yes

  No

  N/A

• Training Documented?

  Yes

  No

  N/A

• Powered Industrial Trucks (forklifts, scissor lifts, boom lifts, powered pallet jacks)

  Yes

  No

  N/A

• Temporary Employee Operators?

  Yes

  No

  N/A

• How Many Temporary Employee Operators?

• Operator Training Program?

  Yes

  No

  N/A

• Class Format

• Designated Trainer

• Written Test?

  Yes

  No

  N/A

• Driving Test?

  Yes

  No

  N/A

• Daily Operator Inspections?

  Yes

  No

  N/A

• Verify Inspection Records

• Type of Equipment

• Respiratory Protection

  Yes

  No

  N/A

• Written Program

  Yes

  No

  N/A

• Temporaries Wear Respirators Either Voluntary or Mandatory?

  Yes

  No

  N/A

• Allow Voluntary Usage?

  Yes

  No

  N/A

• Appendix D Signed?

  Yes

  No

  N/A

• Type of Respirator Used for Voluntary Usage

• IH Testing Been Completed Identifying Hazards?

  Yes

  No

  N/A

• Hazards Identified?

  Yes

  No

  N/A

• Types of Respirators Used

• Dust Mask

  Yes

  No

  N/A

• Half Mask Cartridge

  Yes

  No

  N/A

• Full Face Respirator

  Yes

  No

  N/A

• SAR

  Yes

  No

  N/A

• Other

• Fit Testing

  Yes

  No

  N/A

• Banana Oil

  Yes

  No

  N/A

• Bitrix

  Yes

  No

  N/A

• Irritant Smoke

  Yes

  No

  N/A

• Medical Testing

  Yes

  No

  N/A

• Temporary Employees Tested Prior to Wearing Respirator?

  Yes

  No

  N/A

• PFT's

  Yes

  No

  N/A

• Annual Exam?

  Yes

  No

  N/A

• Training Program?

  Yes

  No

  N/A

• Training Documented?

  Yes

  No

  N/A

• Notified Client of Medical Testing Responsibilities Under OSHA

  Yes

  No

  N/A

• Lockout / Tagout Program

  Yes

  No

  N/A

• Do Temporary Employees Conduct authorized LOTO in the Facility?

  Yes

  No

  N/A

• If Yes..... Do They Receive Authorized Training?

  Yes

  No

  N/A

• Types of Training

• Affected

  Yes

  No

  N/A

• Authorized

  Yes

  No

  N/A

• Written Procedures for each Piece of Equipment?

  Yes

  No

  N/A

• Updated?

  Yes

  No

  N/A

• Last Annual Review

• Reviews Documented?

  Yes

  No

  N/A

• Hearing Conservation

  Yes

  No

  N/A

• Do You Have Areas That Exceed OSHA Noise Levels of 85 dBA?

  Yes

  No

  N/A

• Written Program Required

  Yes

  No

  N/A

• Do Temporary Employees Work in Areas Where Hearing Protection is Required?

  Yes

  No

  N/A

• 8 hr TWA Noise Testing Complete?

  Yes

  No

  N/A

• Date of Last Sample

• Base Line Testing for Temporary Employees within 6 months of exposure?

  Yes

  No

  N/A

• Annual Testing for Temporary Employees

  Yes

  No

  N/A

• Training Provided for Hearing Protection?

  Yes

  No

  N/A

• Training Documented?

  Yes

  No

  N/A

• Verify

• Notified Client of Test Responsibilities Under OSHA

  Yes

  No

  N/A

• Confined Space

  Yes

  No

  N/A

• Does Facility Have any Confined Spaces Either Permit / Non-permit?

  Yes

  No

  N/A

• Written Program?

  Yes

  No

  N/A

• Do Temporary Employees Enter Permit / Non-permit Confined Spaces?

  Yes

  No

  N/A

• Are the Temporary Employees Trained Before Entry?

  Yes

  No

  N/A

• Training Documented?

  Yes

  No

  N/A

• Incident Investigations

  Yes

  No

  N/A

• Incident investigations Completed for all Incidents?

  Yes

  No

  N/A

• Root Cause and Corrective Action Well Documented?

  Yes

  No

  N/A

• First aid Incidents Investigated?

  Yes

  No

  N/A

• Near Misses Investigated?

  Yes

  No

  N/A

• Are Trends Identified?

  Yes

  No

  N/A

• Review Completed Reports

• Fall Protection Program

  Yes

  No

  N/A

• Written Program?

  Yes

  No

  N/A

• Temporary Employees Required to Use Fall Protection?

  Yes

  No

  N/A

• Types of Fall Protection

• Waist Belt

• Full Body Harness

• Lanyard

• Fall limiter

• Training Given for Fall Protection?

  Yes

  No

  N/A

• Training Documented?

  Yes

  No

  N/A

• Fall Protection Inspection Program

  Yes

  No

  N/A

• Inspections Documented?

  Yes

  No

  N/A

• HazCom Program

  Yes

  No

  N/A

• Written Program?

  Yes

  No

  N/A

• SDS Documents Kept?

  Yes

  No

  N/A

• Location of SDS

• Who is Responsible to Update SDS?

• HazCom Training

  Yes

  No

  N/A

• New GHS Training Requirements Completed?

  Yes

  No

  N/A

• Training Completed?

  Yes

  No

  N/A

• Training Documented?

  Yes

  No

  N/A

• Electrical Safety Program

  Yes

  No

  N/A

• Written Program

  Yes

  No

  N/A

Machine Guarding

• Does Client have Equipment Requiring Guarding?

  Yes

  No

  N/A

• Types of Guarding Observed?

• Type of Equipment

• Appear to be Effective?<br><br>Note: This audit did not conduct a thorough machine inspection nor did it watch machine cycles to determine effectiveness of guarding or that all point of operations are protected.

  Yes

  No

  N/A

• Is Guarding Easily Identifiable on Equipment?

  Yes

  No

  N/A

• Does Client Have Any Presses? (Brake Press, Mechanical)

  Yes

  No

  N/A

• If so.....Type of Guarding

• 2 Hand Operation (Palm Buttons, Finger Sensing, PSD, or Other 2 Hand Operation)

  Yes

  No

  N/A

• Foot Pedal or Treadle Properly Guarded Against Unintended Object Strikes?

  Yes

  No

  N/A

• Is Client Aware of Requirement to Report Point of Operation Injuries to OSHA within 30 days? (29CFR1910.217(g)(1))

  Yes

  No

  N/A

Facility Walk-thru

• OSHA Poster

  Yes

  No

  N/A

• Workers Compensation Poster

  Yes

  No

  N/A

• Emergency Evacuation Posted

  Yes

  No

  N/A

• Fire Extinguishers Available

  Yes

  No

  N/A

• Marked with Signs

  Yes

  No

  N/A

• Accessible - Not Blocked

  Yes

  No

  N/A

• First Aid Supplies

  Yes

  No

  N/A

• Marked with Signs

  Yes

  No

  N/A

• Accessible - Not Blocked

  Yes

  No

  N/A

• Housekeeping

  Safe

  At Risk

  N/A

• Work Areas Clear of Trip Hazards

  Safe

  At Risk

  N/A

• Walkways Clear - No Obstructions

  Yes

  No

  N/A

• PPE Being Worn Properly

  Yes

  No

  N/A

• Machine Guarding

  Safe

  At Risk

  N/A

• HazCom - Container Properly Labeled

  Yes

  No

  N/A

• Flammables Properly Stored

  Yes

  No

  N/A

• Material Handling

  Safe

  At Risk

  N/A

• 50#'s or less

  Yes

  No

  N/A

• Twisting

  Safe

  At Risk

  N/A

• Bending

  Safe

  At Risk

  N/A

• Reaching

  Safe

  At Risk

  N/A

• Pushing / Pulling

  Safe

  At Risk

  N/A

• Powered Industrial Truck Being Operated Safety

  Safe

  At Risk

  N/A

• Drivers Wearing Seatbelts

  Safe

  At Risk

  N/A

• Pre-shift Inspection Completed

  Yes

  No

  N/A

Facility Observations

• Observation 1

• Observation 2

• Observation 3

• Observation 4

• Observation 5

Overall Facility Summary

• Summary

Overall Facility Rating

• Select from range