Accident Investigation Form
Designated Medical Provider
Safety Inspections
Office Safety Inspection
Shop Safety Inspection
County Employer Group office Safety Inspection Checklist
Slips,Trips and Falls
Electrical Safety
Office Equipment
Fire Protection/Prevention/Exits
Medical Services and First Aid
General Work Environment
Stairs and Stairways
County & Inspectors
Slips,Trips and Falls
Slips,Trips and Falls
1. Are floors clean of litter and/or spilled liquid?
Yes
No
DNA
2. Are floor surfaces chipped and uneven, or does carpeting show worn spots or holes?
Yes
No
DNA
3. Are aisles and walkways free of boxes, wastebaskets, chairs, and other obstacles that impede traffic?
Yes
No
DNA
4. Do employees understand they are not allowed to stand on chairs, desks, boxes, drawers, or other improvised ladders?
Yes
No
DNA
5. Are stairs free of litter, boxes, scraps, and spills?
Yes
No
DNA
6. Do stairways have handrails?
Yes
No
DNA
7. Are stair handrails, treads, and risers in good condition and stairs well lighted?
Yes
No
DNA
8. Are steps, sidewalks, and walk areas clean of snow and ice?
Yes
No
DNA
9. Are changes of elevation or direction marked or easily recognized?
Yes
No
DNA
10. Are floors dry and free of slip hazards?
Yes
No
DNA
11. Are floors and walkways free of trip hazards?
Yes
No
DNA
Electrical Safety
Electrical Safety
1. Are electric and telephone cords placed where they might trip others?
Yes
No
DNA
2. Do electrical cords look frayed? Are they draped over hot pipes, bent around hooks or sharp edges, or are they being stepped on?
Yes
No
DNA
3. Are poorly made or flimsy extension cords in use? (check for tape around cord that could be covering cracks in cord jacket, and exposed wires on cord and plug)
Yes
No
DNA
4. Are all appliances/office equipment and extension cords connected with three-pronged plugs? (check for ground plugs that may have been broken off)
Yes
No
DNA
5. Do coffee pots, microwaves, or other appliances carry an Underwriters Laboratory (UL) listing for electrical safety?
Yes
No
DNA
6. Are switches, outlets, etc. provided with tight-fitting covers or plates? (damaged/cracked faceplates should be replaced)
Yes
No
DNA
7. Are all electrical panels/cabinets secured and accessible to only authorized employees?
Yes
No
DNA
8. Is there at least 3 feet of unobstructed space in front of all electrical panels/cabinets? (nothing should be stored below or in front of these cabinets)
Yes
No
DNA
9. Are single use extension cords and are multiple outlet units (power strips) plugged directly into a wall unit?
Yes
No
DNA
10. Are cords adequately covered or are guards provided across an isle or other passageway?
Yes
No
DNA
11. Do all space heaters have a working tip over switch (automatic shutoff)?
Yes
No
DNA
12. Are combustibles kept 3 feet from the sides and tops of all heat sources?
Yes
No
DNA
13. Are space heaters on the floor?
Yes
No
DNA
14. Are space heaters plugged directly into a wall outlet or power strip?
Yes
No
DNA
15. Do the multiple outlets (power strips) have a circuit breaker?
Yes
No
DNA
Office Equipment
Office Equipment
1. Are any desk drawers or file drawers left open and could cause a hazard?
Yes
No
DNA
2. Are files, lockers, cabinets, and bookcases sitting level and secure to prevent tipping?
Yes
No
DNA
3. Are files cabinets top-heavy, with empty drawers at the bottom and full drawers on top?
Yes
No
DNA
4. Are an excessive amount of boxes, papers, and books stored on top of files, storage cabinets, or windowsills?
Yes
No
DNA
5. Are overhead vents and lighting fixtures damaged or hanging loose?
Yes
No
DNA
Fire Protection/Prevention/Exits
Fire Protection/Prevention/Exits
1. Is the local fire department familiar with the layout of your facility and have they toured the site to become familiar with the operations and potential hazards in the event of a fire? If yes, when was the last time the fire department toured your facility?
Yes
No
DNA
2. Are fire/emergency exits clearly marked and free of obstructions?
Yes
No
DNA
3. Are exit lights or signs present and in proper working condition?
Yes
No
DNA
4. Are emergency escape plans posted?
Yes
No
DNA
5. Are emergency exits, including aisles/hallways free of obstructions?
Yes
No
DNA
6. Are fire extinguisher locations marked (usually at ceiling height on the wall) so they are visible from a distance?
Yes
No
DNA
7. Is the needle on the fire extinguishers in the green zone indicating charged/ready?
Yes
No
DNA
8. Do all employees know the location of exits, alarms, and extinguishers?
Yes
No
DNA
9. Are emergency numbers posted for police, fire department, and ambulance?
Yes
No
DNA
10. Are fire drills conducted frequently (at least semi-annually)? Last date drill conducted:
Yes
No
DNA
11. Are sprinklers and fire detectors clean and in good working order?
Yes
No
DNA
12. Are doors to enclosed stairwells kept closed at all times?
Yes
No
DNA
13. Are employees trained on proper evacuation procedures in the event of an emergency?
Yes
No
DNA
14. Is there at least 18 inches of clearance below any automatic sprinkler heads?
Yes
No
DNA
15. Are there an adequate number (one every 50 feet) and type of portable fire extinguishers?
Yes
No
DNA
16. Are the fire extinguishers mounted in well-marked accessible locations?
Yes
No
DNA
17. Are all portable fire extinguishers inspected and recharged annually and are the inspection tags up to date and located on the fire extinguisher?
Yes
No
DNA
18. Are doors, aisles, and stairways that could be confused as exits marked with signs such as NOT AN EXIT?
Yes
No
DNA
19. Are exits properly maintained and free of snow and ice obstructions (winter only)?
Yes
No
DNA
Medical Services and First Aid
Medical Services and First Aid
1. Do you have trained emergency responders on staff? If yes, please specify their names
Yes
No
DNA
2. Are first aid kits accessible and are they stocked with appropriate supplies?
Yes
No
DNA
3. Is there a procedure to periodically survey and replace the items in the first aid kits? If yes, how often are the first aid kits checked? Who is responsible for checking the first aid kits
Yes
No
DNA
4. Do you have emergency eyewash products for exposure to acids, caustics, corrosives, etc.?
Yes
No
DNA
General Work Environment
General Work Environment
1. Are restrooms clean and toilets and washing facilities sanitary?
Yes
No
DNA
2. Are all work areas adequately illuminated?
Yes
No
DNA
3. Are all work surfaces clean, dry, and free of obvious defects?
Yes
No
DNA
4. Are portable step stools/ladders available to get items down from high surfaces?
Yes
No
DNA
5. Are portable carts available to transport heavy journals/items?
Yes
No
DNA
6. Are pits and floor openings covered or guarded by standard guard rails?
Yes
No
DNA
7. Are employees required to wear safety orange or other safety colored vests/clothing whenever necessary during various county projects?
Yes
No
DNA
Stairs and Stairways
Stairs and Stairways
1. Are standard handrails installecl on all stairs having four or more risers?
Yes
No
DNA
2. Do open stairways have handrails and are they adequately braced?
Yes
No
DNA
3. Are all stairways at least 22 inches wide and have at least a 6'6 vertical clearance?
Yes
No
DNA
4. Are step risers in good condition?
Yes
No
DNA
5. Are steps designed or provided with a slip-resistant surface?
Yes
No
DNA
6. Are adequate barriers & warnings provided where stairwells exit directly into office traffic?
Yes
No
DNA
7. Are stairways clear and free of any objects? (ex: boxes, coolers, water jugs, etc...)
Yes
No
DNA
8. Are floor tiles and all carpeting in good condition?
Yes
No
DNA
9. Are step risers uniform from top to bottom with no riser spacing greater than 7.5 inches?
Yes
No
DNA
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Department
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Date
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Name of Inspector/Inspectors
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Management Review
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