Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Location

Exterior Grounds/ Walking Surfaces

  • Are parking lots/sidewalks free of slip, trip and fall hazards?

  • Are stairs/ramps in good condition and provided with appropriate handrails?

  • Are curbs in good condition and not crumbling?

  • Is exterior lighting adequate throughout premises? Is lighting bright enough to clearly see at night?

  • Are the edges of outdoor steps marked with white or bright yellow paint to increase step visibility at night?

  • Have all potholes, uneven walkways or parking areas been patched to eliminate falling hazards?

  • If any gas pumps are out of order, are they labeled properly?

  • TRASH: No accumulations of trash? Dumpsters outside have lid when not in use? Fire damper doors in working condition?

  • Misc/Other

  • Misc/Other

Interior- Front of Store

  • Are water absorbent mats used at all entrances?

  • Are mats in good condition without curled edges, tears, and unlevel areas

  • Are interior floor surfaces in good condition?

  • Are floors dry and clear of debris?

  • Is there a spill clean-up procedure in place with spill kits?

  • Are “Caution Wet Floor” signs available used for freshly mopped areas or spills?

  • If wet floor signs were present during the time of visit, were they put away once the floor was dry?

  • Is there a mat in front of the refreshment station?

  • Is the general housekeeping adequate and not presenting any tripping hazards?

  • Are walking areas free of appliances or extension cords?

  • Are the aisle ways clear of boxes and excess materials?

  • ATM security- are there cameras present and is the ATM located in a visible area?

  • Misc/Other

  • Misc/Other

Food Handling

  • Are proper food handling procedures in place?

  • Are employees washing hands before and after handling food? Are hand washing signs present?

  • Are disposable gloves worn when handling food and being changed between handling customer transactions?

  • Are gloves available when handling hot objects?

  • Are employees trained on proper knife usage?

  • Is there designated knife storage and are knives being put away when not actively being used?

  • Is there a deep fat fryer present? If so, is there at least 18 inches of clearance (or a baffle) if positioned next to an open flame?

  • Is a properly rated K class fire extinguisher nearby and in working order?

  • Are all hoods, exhaust ducts and fans clean and free of grease and inspected every 3 months?

  • Is there an ANSUL fire suppression system in place and inspected at least every 6 months?

  • Are all electrical appliances grounded and wiring in good conditions?

  • Are electrical outlets near the sink on a ground fault circuit interrupter (GFCI)?

  • Are all cooking and prep areas clean, sanitary, and orderly?

  • Misc/Other

  • Misc/Other

Restrooms

  • Are the restrooms in a dry, clean and in sanitary condition?

  • Is the towel dispenser and trash can located adjacent to the sink? (not across the room where customers drip water on the floor)

  • Are there employee handwashing signs present?

  • Misc/Other

Interior- Back of Store

  • Is the general housekeeping adequate and not presenting any tripping hazards?

  • Are wet floor signs available? Are they being used as appropriate?

  • Are electrical panels clear at least 36 inches (no items being stored in front)? Are they closed?

  • Is the floor in front of the ice machine kept dry and not leaking? Is there a mat present?

  • Is there an eyewash station present? Is it inspected and not obstructed with clear access?

  • Is there a sharps container? Is it property maintained?

  • Is the dishwashing area floor dry and floor mats present?

  • Are Safety Data Sheets provided and kept updated for all chemicals/products handled by employees?

  • Are ladders in good condition without defaced/worn labels (Load Capacity), and without damage to rails, rungs, slip-resistant footing? Take photo of any ladder or step stool present***

  • Are exterior doors equipped with peep holes?

  • Storage areas- are heavy boxes not being stored on top shelves?

  • Is cash properly secured and a safe being used to storage valuables?

  • Misc/Other

  • Misc/Other

Life Safety

  • Are exit doors equipped with illuminated exit signs? Are they not blocked and clear of obstructions?

  • Are exit doors equipped with panic hardware?

  • Are exit signs properly displayed and illuminated?

  • Are facilities equipped with emergency lighting?

  • Are doorways/halls/aisles free from obstruction?

  • Have emergency preparedness procedures been implemented, including staff training and drills?

  • Have portable fire extinguishers been inspected annually and documented on the tag?

  • Has a monthly visual check of the portable fire extinguishers been conducted and documented on the back of the tag?

  • Are portable fire extinguishers charged and mounted properly on the wall for immediate access?

  • Are portable fire extinguishers accessible and not blocked?

  • Is there a fire suppression system in place? If so, is it properly inspected and maintained?

  • Are all sprinkler heads provided with at least 18 inches of clearance?

  • Are smoke detectors in place? Are they hardwired and being property maintained/ inspected?

  • Misc/Other

  • Misc/Other

Administrative

  • Is there a safety orientation in place for new employees? Is it documented?

  • Are there safety policies and procedures in place? Are they enforced?

  • Are regular inspections of the facility conducted to recognize and correct hazards? Are they documented?

  • Are incident investigations conducted when employees or customers are injured and is the investigation documented?

  • Is there a Return-to-Work Program (Light Work Duty) in place for injured employees?

  • Are appropriate employment posters including the OSHA poster displayed for employees to view?

  • Is an adequate first aid kit provided and kept well stocked? Bodily Fluid Clean-up Kit available?

  • Misc/Other

  • Misc/Other

Security

  • Are surveillance cameras installed and operable with full coverage for the exterior, interior and parking lot?

  • Do the surveillance cameras record and have the ability to save and recall at least 30 days of information?

  • Have 911 Panic Buttons been provided and located in an inconspicuous location at the cash registers?

  • Are facilities protected by a UL listed burglar alarm system connected to a central station?

  • Are all exterior fences in good condition?

  • Are all delivery personnel and vendors monitored while onsite?

  • Are there sigs of vandalism or graffiti?

  • Misc/Other

  • Misc/Other

  • Is the public viewing monitor (CCTV) in working condition?

  • Do you have an understanding of how to arm and disarm the alarm panel keypad?

FUELING STATIONS

  • Is there an emergency shut off switch for gas lines?

  • Are hoses inspected on a regular basis?

  • Is a spill kit available for gasoline?

  • Are fire extinguishers available and serviced?

  • Are gas caps securely tightened on the ground?

  • Is tamper proof tape on each of the fueling stations?

  • Are gas pumps primed every day?

  • Are card readers inspected for data swiping devices?

  • Misc/Other

  • Misc/Other

Other Observations

  • Are there any other observations to note?

  • Are there any other observations to note?

  • Are there any other observations to note?

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.