WORKPLACE EVALUATION CHECKLIST & REPORT
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- Anastasia Gregory
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1 Work Center: Supervisor: Telephone Number: Building & Room Number: Date of Last Evaluation: Date: WORKPLACE EVALUATION CHECKLIST & REPORT ITEM YES NO N/A COMMENTS Has this area been surveyed in the last year? 1.0 GENERAL SAFETY a. Light levels adequate? b. Air filters/diffusers c. Work area s GENERAL housekeeping orderly? d. Work area ambient temperature acceptable? e. Work are ambient f. Are OSHA warning signs/posters properly posted? g. Are trips, slips, and fall hazards properly managed? 1.1 Are personnel exposed to on-the-job a. Radiation? b. Noise? c. Chemical vapors, mist, or splash? d. Nuisance Dusts or other airborne particulates? e. Asbestos or other carcinogens? f. Unknown hazards and/or wastes? 1.2 Do personnel routinely work a. In confined spaces? b. On elevated platforms? c. Outdoors (in hot or cold weather)? d. Around high energy (electrical or magnetic) e. Around low energy (electrical or magnetic) f. On ladders? g. With compressed gasses? h. Around infectious agents (blood, urine, saliva, study animals, etc)? Appendix C-1 1
2 Documented? 2.0 TRAINING RECEIVED IN THE LAST YEAR YES NO N/A YES NO N/A a. General Safety? b. Evacuation Coordinator? c. Fire or Emergency Evacuation? d. Fire Extinguisher? e. Equipment operation & maintenance? f. Chemical or Biological Hazard Safety? g. Pollution Prevention & Protection? h. Forklift Safety? i. Energy Sources Lock out/tag Out? j. Hazardous Waste Management & Control? k. Radiation Safety? l. Heat /Cold Stress? m. Confined Spaces? n. Hot Works? o. Working on Elevated Surfaces? p. Machine Guarding? q. Personal Protective Equipment (PPE)? r. Respiratory Protection? s. Hearing Conservation Program? 3.0 PROTECTIVE EQUIPMENT ON HAND YES NO N/A a. Head (Hard Hat)? b. Eye & Face (Goggles, Face Shield(s), Welding Masks)? c. Body (Respirators, Coveralls, Aprons)? d. Hands (Gloves)? e. Legs & Feet (Shin guards, Safety Shoes, Toe Guards)? f. Machine guards? 3.1 Are shop personnel respirator certified? a. Has the shop supervisor developed a Respiratory Protection Plan (RPP)? b. Is RPP current and updated annually? c. Is certification more than 1 year old? d. Has re-certification been scheduled? 4.0 ELECTRICAL SAFETY YES NO N/A a. Electrical panel properly labeled? b. Access to electrical panel clear? c. Electrical equipment properly grounded? d. Overloaded conduits (extension cords, receptacle multipliers, etc) found? e. Electrical cords appropriately gauged and undamaged? f. Electrical space heaters in use? g. Lock out/tag out procedures available and in use? h. Lock out/tag out procedure training completed and documented? i. Basic electrical safety training completed and documented? Appendix C-1 2
3 5.0 FIRE & LIFE SAFETY YES NO N/A a. Fire extinguishers available within required travel distance (30-50 feet)? b. Fire extinguisher c. Mounted (at least 5 feet above floor)? d. Charged (gauge needle in green zone)? e. Inspected monthly/annually (check tags)? f. Locking pin secured with breakaway maintenance tag? 5.2 Egress path clear and with required travel distance (200 feet unsprinklered/300 feet sprinklered)? 5.3 Exits a. Adequate (2 or more for Assembly Occupancies)? b. Swing in direction of egress? c. Easily seen and unobstructed? d. Marked with working EXIT sign? e. Are all EXIT Signs functional? 5.4 Emergency evacuation procedures a. Current Emergency Evacuation Plan available? b. Is an Evacuation Coordinator needed? c. Has an Evacuation Coordinator been Name: appointed? d. Are fire drills performed (at least) annually? Date of last drill: e. Was last fire drill successful? f. Is manual pull station within 5 feet of exit? g. Is pull station clearly labeled and accessible? 6.0 FIRE ALARM AND NOTIFICATION SYSTEMS YES NO N/A a. Is there a Fire Alarm Control Panel (FACP) in this area? b. Is an inspection label attached to its door? c. What are the label s color and the inspection date? Green RED Date: d. Is the FACP Trouble light OFF or ON? Off ON e. Are smoke detectors functional (check indicator light for intermittent flash) f. Is smoke detector securely attached to the ceiling? g. Is smoke detector installed at lease 3 feet away from air diffusers? h. Is the area around the smoke detector clear and unobstructed? i. Are adequate Audio/Visual (A/V) devices installed (>2 if room is > 20 feet wide)? j. Are A/V devices installed between 80 and 96 inches above the floor? k. Are A/V device installed on opposite walls in Assembly areas and Rooms >20 feet wide? l. Are EXIT Signs in the exit access corridor (hallway) visible within 100 feet of each other? Appendix C-1 3
4 m. Are fire hose cabinets in the area n. Clear and unobstructed? o. Properly and clearly labeled? p. Equipped with nylon hose and Class A (water) fire extinguisher? q. Current emergency evacuation diagram and way-finder maps available? 7.0 FIRE SUPPRESSION SYSTEM YES NO N/A a. Fire Department (Siamese) Connection (FDC) labeled and unobstructed? b. Sprinkler system inspected at least annually? Last inspection date: c. Area around head free and spray pattern unobstructed? d. Distance between bottom of sprinkler head and items stored below it is > 18 inches? e. Combustible material (trash) removed from area daily? f. Horizontal (conduit, utility lines) penetrations sealed with fire-rated caulking? 8.0 PHYSICAL SAFETY a. Compressed gas cylinders: b. Properly secured with chains? c. Separated according to content? d. Separated according to serviceability (full or empty)? 8.1 Has Sound Pressure Levels (SPL) in this area been evaluated and documented? a. Is this a hazardous noise area (SPL >85 Decibels (db) over 8 hour period)? b. Has the shop supervisor developed a Hearing Conservation Plan (HCP)? c. Is the area clearly posted HAZARDOUS NOISE AREA (inside and outside)? d. Is the HCP current and updated annually? e. Do personnel have hearing protection? f. Do personnel routinely wear hearing protection? g. Do personnel receive annual audiometric examinations? 9.0 CHEMICAL SAFETY YES NO N/A a. Do personnel routinely use hazardous chemical? b. Are personnel routine exposed to hazardous chemical vapors? c. Is an inventory of the hazardous chemical to which personnel are exposed available? d. Are Material Safety Data Sheets (MSDSs) (1) Available for chemicals in use? (2) Available for employee review? (3) Location known to employees? e. Do employees know how to read & use MSDSs? Appendix C-1 4
5 f. Are postings: (1) Available? (2) Current? (3) Clearly visible? (4) Pertinent to the hazards in the work area? g. Does work done in the area require exhaust ventilation? h. If available (1) Does exhaust ventilation function properly? (2) Is the ventilation system cleaned annually? Date last cleaned: (3) Is the ventilation system tested and certified annually? Date last tested/certified: File: G:\Physical Safety\Word Files\Reports\Evals Appendix C-1 5
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MINOOKA FIRE PROTECTION DISTRICT Fire Prevention Bureau Fire Inspector Rodney Bradberry Fire Alarm Systems Plan Review Checklist Date: Permit Number: Business Name: Address: Fire Alarm System Submittal
Fort Bragg Fire and Emergency Services Division Fire Safety Survey For use of this form, see FB Reg 420-1, the proponent agency for this form is DES.
Fort Bragg Fire and Emergency Services Division Fire Safety Survey For use of this form, see FB Reg 420-1, the proponent agency for this form is DES. Date of Survey: Building Number: UNIT / Organization:
A. General Safety LAB/ROOM: INSPECTED BY: DATE:
A. General Safety Item Subject Yes, No, A1 Exits are not obstructed, fastened or locked with keys A2 EXIT signs, if installed are clear and illuminated A3 A4 A5 A6 Fire extinguishers and fire blankets