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Client Name: _________________________________________________________________
Location: _________________________________________________________________
Contact(s): _________________________________________________________________
Completed By: _________________________________________________________________
Date: _________________________________________________________________

A - SAFETY PERFORMANCE COMMENTS
Experience Modification Factor?


OSHA 300 Logs Available?


# Of Injuries/Illnesses?


Types of Accidents?



Any identified loss trends?


Any Dept. with excessive injuries?


Job Class Code for Employees?



B - ACCIDENT/INJURY MANAGEMENT COMMENTS
Procedures for Reporting Accidents/Injuries?



Medical Facility Used?



First Aid Capabilities on Premises?


Accident Investigated for Root Cause? View form.


Contact Person for Injury Follow-up?


Can You Accommodate Modified Duty?


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C – SAFETY PROGRAM Yes No N/A
Safety Manual/Employee Handbook?
Written Safety Policy
Written Safety Rules
Employees receive specific listing of safety rules?
Safety Orientation? By who?
Scheduled Refresher Safety Training?
Bi-lingual supervisors?
Hazardous Communication Program
Written Program Available?
List of Chemicals?
MSDS Available?
Chemical Containers Clearly Labeled?
Training Program?
Machine Guarding & Lock Out Tag Out
Points of Operation/Moving Parts Guarded?
Transmission Apparatus/Pinch Points Guarded?
Machine Safeguarded Reviewed with Employee(s)?
Written Lock Out Tag Out Program?
Designated and Affected Employees Trained?
Operating Controls Clearly Labeled?
Emergency Stop Available?
Environmental Exposures
Air Quality Concerns (dust, spray paint, etc.)?
Noise Exposure > 85 dBA?
Employees in High Noise Area Given Baseline (Upon
Placement) & Annual Audiometric Testing?

Hot/Cold Temperatures/Wet Environment?
Industrial Trucks (i.e. Forklifts)
Designated Operators?
Operators Certified?
Regular Operator Safety Training?
Frequency of Training?
Truck Trailers Wheels Chocked & Secured to Dock
Observe Safe Industrial Truck Operation?
Employee Placement Near High Industrial Truck Traffic?
Hoists and Auxiliary Equipment
Designated Operators?
Operator Training?
Controls Plainly Marked for Direction of Travel?
Ropes, Slings, Hooks in Good Condition?
Fire Safety
Emergency Evacuation Program?
Emergency Evacuation Training for Employees?
Emergency Drills Conducted?
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C – SAFETY PROGRAM Continued Yes No N/A
Exits Marked with Illuminated Signs?
Paths to Exits Free of Obstructions
Sufficient Number of Exits Available?
Electrical Wiring Deficiencies?
Accessible Fire Extinguishers?
Employee Fire Extinguisher Training?
NO SMOKING Signs & Enforced?
Safe Welding Practices?
Hand Tools and Equipment
Tools in Good Condition?
Tools & Equipment Regularly Inspected?
Grinders, Saws & Portable Tools Properly Guarded
Rotating/Moving Parts Adequately Guarded?
Openings & Elevated Work Surfaces
Guardrails & Perimeter Protection for Platforms, Balconies and
Floor Openings?

Stairs Slip Resistant?
Stair Handrails?
Stairways Well Lit?
Housekeeping
Aisles Clear and Well Marked?
Water, Oil or Other Liquids on Floor?
Ice & Snow Removal for Sidewalks & Lots?
Adequate Lighting?
Wet Surfaces Slip Resistant?

D - ERGONOMIC INFORMATION COMMENTS:
How are ergonomic concerns assessed and corrected?
Repetitive Hand/Wrist/Arm Movement Required?
Repetitious – 2000 hand movements/hour continuous
Excessive Reaching, Pulling?
Bending, Stooping, Twisting, Motions for Extended
Time?

Standing for Extended Period of Time
Excessive or Extreme Vibration?
Weight Lifted or Carried / frequency of?
Up to 10 Pounds?
11 to 25 Pounds?
26 to 50 Pounds?
If > 50 Pounds, # of Pounds?
Lifting Objects Between Knuckle & Shoulder Height?
Lifting Devices Available & Used?

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E - PERSONAL PROTECTIVE EQUIPMENT (PPE) Required? Provided? Enforced?
Designated PPE areas appropriately marked? Yes No
Goggles/Face Shield Yes No Yes No Yes No
Safety Glasses Yes No Yes No Yes No
Gloves/Aprons Yes No Yes No Yes No
Hard Hats Yes No Yes No Yes No
Foot Protection Yes No Yes No Yes No
Respirators Yes No Yes No Yes No
Hearing Protection Yes No Yes No Yes No

F - MISCELLANEOUS COMMENTS:
Dedicated supervisor for area where EE's will work?
Number of Client Employees?
Number of Staffing Service Employees Used?
Number Requested of Our Staffing Agency?
Reason for Utilizing Our Services?



Hiring Temp to Perm placement?
Hiring day labor work positions?
Time Keeping (Punch Card/Swipe Card, etc.)


What Entrance to be Used By Staffing Employees?


Designated Smoking Areas?
Lunch Room Provided?
Lockers/Safe Storage of Personal Items?
Work at heights? Explain



Will employee operate machines? Explain



Will employee assist machine operators? Explain



Will employee drive any vehicles (auto/truck)? Explain


Will the EE be operating any power machinery/tools?
Is there a procedure to identify, evaluate, and correct
workplace hazards?


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G - TEMPORARY EMPLOYEES INITIAL SAFETY TRAINING? CLIENT STAFFING AGENCY
Specific hands on safety training for job hazards? Yes No N/A
Specific hands on safety training for new job hazards? Yes No N/A
General Safety Policy, Rules & Procedures? Yes No N/A
Hazardous Communication? Yes No N/A
Machine Guarding? Yes No N/A
Lock Out/Tag Out? Yes No N/A
Emergency Evacuation? Yes No N/A
Fire Safety? Yes No N/A
PPE? Yes No N/A
Hearing Conservation? Yes No N/A
Bloodborne Pathogens? Yes No N/A
Electrical? Yes No N/A
Hoists & Slings? Yes No N/A
Hand Tools Inspection? Yes No N/A
Housekeeping? Yes No N/A
Safe Lifting Techniques? Yes No N/A

H - ADDITIONAL COMMENTS:

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