SNRC Individual Worker Assessment v2015-07

• Date

  Date

• Document No.

• Employee Name

• Auditor Name

• Location
  Address

Required PPE * Company Supplied Equipment

• Clothing (correct layering, rain gear, etc)

  Yes

  No

  Not Applicable for job

• Time Piece (watch, phone, IPad, etc)

  Yes

  No

• *Safety glasses

  Yes

  No

  Not Applicable for job

• *Hearing Protection

  Yes

  No

  Not Applicable for job

• *Radio Fully Charged

  Yes

  No

• All Company Equipment tethered to vest

  Yes

  No

  Not Applicable for job

• First Aid Certification up to date?

  Yes

  No

• Matches or Lighter for emergency use

  Yes

  No

• *Whistle on gear?

  Yes

  No

• *Survival Blanket

  Yes

  No

• *Compass?

  Yes

  No

• *Flashlight/Headlamp (headlamp not supplied by company)

  Yes

  No

  Not Applicable for job

• Emergency use knife/multitool

  Yes

  No

• Water and food

  Yes

  No

Required PPE General Condition

• Rain gear

  Good

  Fair

  Poor

  Lost

• *Hard hat and visor. (Yearly replacement of liner)

  Good

  Fair

  Poor

  Lost

• *Hand protection

  Good

  Fair

  Poor

  Lost

• High visibility vest

  Good

  Fair

  Poor

  Lost

• Boots? Condition? Caulks sharp?

  Good

  Fair

  Poor

  Lost

• *Personal first aid kit? (min: 1 pressure dressing, 6-10 band aids, 6-10 cleansing towels)

  Good

  Fair

  Poor

  Lost

• *PFD Vest condition and CO2 canister in good condition

  Good

  Fair

  Poor

  Lost

Optional Recommended PPE

• Bear spray

  Yes

  No

  Not Applicable for job

• Bear Banger

  Yes

  No

  Not Applicable for job

• Cougar knife

  Yes

  No

  Not Applicable for job

• Bug spray

  Yes

  No

  Not Applicable for job

• Bug Net

  Yes

  No

  Not Applicable for job

• Benadryl (antihistamine)

  Yes

  No

  Not Applicable for job

• Sun Screen

  Yes

  No

  Not Applicable for job

• Corrective Actions, Responsibility and Due Date

• Other deficiencies Identified

• Auditor Signature

  Sign

• Add signature

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