Accident Investigation Form
Designated Medical Provider
Safety Inspections
Office Safety Inspection
Shop Safety Inspection
County Employer Group shop Safety Inspection Checklist
Medical Services and First Aid
Fire Protection
Personal Protective Equipment
General Work Environment
Walkways and Floor Openings
Stairs and Stairways
Elevated Work Surfaces/Platforms/Scaffolds
Life Safety Code Features
Portable Ladders
Hand Tools and Equipment
Portable Power Tools and Equipment
Abrasive Wheel Equipment and Grinders
Machine Guarding
Electrical
Lockout/Tagout Procedures
Welding, Cutting, and Brazing
Compressors and Compressed Air
Hoisting Equipment
Powered Industrial Trucks and Forklifts/Heavy Equipment
Storage
Occupational Noise Exposure
Hazard Communication "Right-to-Know"
County & Inspectors
Medical Services and First Aid
Medical Services and First Aid
1. Do you have any trained emergency responders on staff? If yes, please list 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
Fire Protection
Fire Protection
1. Is there at least 18 inches of clearance below any automatic sprinkler heads?
Yes
No
DNA
2. Are there an adequate number (one every 50 feet) and type of portable fire extinguishers?
Yes
No
DNA
3. Are the fire extinguishers mounted in well-marked accessible locations?
Yes
No
DNA
4. 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
5. Are employees periodically instructed/trained in the use of fire extinguishers and fire protection/prevention procedures?
Yes
No
DNA
6. Is the needle on the fire extinguishers in the green zone indicating charged/ready?
Yes
No
DNA
7. Are fire extinguishers present in county vehicles and heavy equipment?
Yes
No
DNA
Personal Protective Equipment
Personal Protective Equipment
1. Are protective goggles, face shields, disposable face masks, or safety glasses with side shields worn where there is a danger of flying particles or corrosive materials?
Yes
No
DNA
2. Are protective aprons, gloves, shields, or other means used against cuts, corrosive liquids, and chemicals?
Yes
No
DNA
3. Are hard hats used where there is a danger from falling objects, impact, or electrical hazards?
Yes
No
DNA
4. Is safety footwear used where there is a risk of foot injuries from falling objects, crushing, or penetration hazards?
Yes
No
DNA
5. Are adequate work procedures, protective clothing, and safety equipment used when cleaning up spilled hazardous materials?
Yes
No
DNA
6. What personal protective equipment is provided by the county? (ex: safety glasses, gloves, hard hats, shields, ear plugs, ear muffs, disposable face masks, or respirators, etc...)
Yes
No
DNA
General Work Environment
General Work Environment
1. Are all work areas clean and orderly?
Yes
No
DNA
2. Are all work surfaces clean, dry, and free of obvious defects?
Yes
No
DNA
3. Are spilled materials cleaned up promptly?
Yes
No
DNA
4. Are covered metal waste containers used for oily or paint-soaked waste materials such as rags and paper towels?
Yes
No
DNA
5. Are restrooms clean and toilets and washing facilities sanitary?
Yes
No
DNA
6. Are all work areas adequately illuminated?
Yes
No
DNA
7. Are pits and floor openings covered or guarded by standard guard rails?
Yes
No
DNA
8. Are employees required to wear safety orange or other safety colored vests/clothing whenever necessary during various county projects?
Yes
No
DNA
Walkways and Floor Openings
Walkways and Floor Openings
1. Are aisles and passageways marked and kept clear for ease of travel?
Yes
No
DNA
2. Is there safe clearance for walking in aisles where motorized or materials handling equipment is used?
Yes
No
DNA
3. Are changes of elevation or direction marked or easily recognized?
Yes
No
DNA
4. Are aisles that pass near moving or operating machinery, welding, or similar operations arranged to protect employees from hazards?
Yes
No
DNA
5. Is adequate headroom provided for the entire length of aisles, walkways, and work platforms?
Yes
No
DNA
6. Are standard guardrails provided along the entire length of open sided floors elevated more than 48 inches?
Yes
No
DNA
7. Are grates or covers over floor openings designed to provide a smooth surface that minimizes tripping hazards?
Yes
No
DNA
8. Are road signs off of the floor and stored properly?
Yes
No
DNA
9. Are cutting edges stacked properly and stored so they do not present a hazard?
Yes
No
DNA
10. Are old cutting edges disposed of properly and not left lying around?
Yes
No
DNA
11. Are floors dry and free of slip hazards?
Yes
No
DNA
12. Are floors and walkways free of trip hazards?
Yes
No
DNA
Stairs and Stairways
Stairs and Stairways
1. Are standard handrails installed 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 step risers uniform from top to bottom with no riser spacing greater than 7.5 inches?
Yes
No
DNA
4. Are steps designed or provided with a slip-resistant surface?
Yes
No
DNA
5. Are adequate barriers & warnings provided where stairwells exit directly into vehicle traffic?
Yes
No
DNA
6. Are stairways clear and free of any objects? (ex: boxes, coolers, water jugs, etc...)
Yes
No
DNA
Elevated Work Surfaces/Platforms/Scaffolds
Elevated Work Surfaces/Platforms/Scaffolds
1. Is a permanent means of access and egress provided for elevated storage and work surfaces?
Yes
No
DNA
2. Is material stored on elevated surfaces piled, stacked, or racked in a manner to prevent tipping, falling, collapsing, or rolling?
Yes
No
DNA
Life Safety Code Features
Life Safety Code Features
1. Do you require more than one employee to be present when backing vehicles into shops?
Yes
No
DNA
2. Are employees trained on getting in and out of vehicles and heavy equipment properly?
Yes
No
DNA
3. Are there at least two exits in the shop for prompt and orderly escape?
Yes
No
DNA
4. Are all exits marked with an exit sign?
Yes
No
DNA
5. Are all exit signs properly illuminated?
Yes
No
DNA
6. Are the directions to exits, when not immediately apparent, marked with visible signs?
Yes
No
DNA
7. Are doors, aisles, and stairways that could be confused as exits marked with signs such as NOT AN EXIT.
Yes
No
DNA
8. Are all exits and access to exits free of obstructions for ease of travel?
Yes
No
DNA
9. Are exits properly maintained and free of snow and ice obstructions (winter only)?
Yes
No
DNA
10. Are sidewalks, steps, and walk areas clear of snow and ice?
Yes
No
DNA
Portable Ladders
Portable Ladders
1. Are all portable ladders maintained and in good condition?
Yes
No
DNA
2. How often are ladders inspected and who is responsible for inspecting the ladders?
Yes
No
DNA
3. Are non-slippery safety feet provided on each ladder?
Yes
No
DNA
4. Are ladder rungs and steps free of grease and oil?
Yes
No
DNA
5. Are broken or damaged ladders removed from service, tagged, or segregated to prevent further use?
Yes
No
DNA
6. When used to access elevated platforms and work areas, are ladders sufficiently long to extend at least 3 feet above the landing surface?
Yes
No
DNA
7. Are the tops of extension ladders tied-off to a secure point whenever possible to prevent displacement or tipping?
Yes
No
DNA
8. Are portable metal ladders legibly marked with signs reading DO NOT USE AROUND ELECTRICITY?
Yes
No
DNA
9. Are employees trained to use stepladders with the side braces in the locked positions and the top two steps not used to stand on?
Yes
No
DNA
10. Are all new ladders purchased fiberglass rather than metal?
Yes
No
DNA
Hand Tools and Equipment
Hand Tools and Equipment
1. Are all company and employee-owned tools in good condition?
Yes
No
DNA
2. Are hand tools such as chisels and punches, which develop mushroomed heads during use, in good working order?
Yes
No
DNA
Portable Power Tools and Equipment
Portable Power Tools and Equipment
1. Are grinders, saws, and similar equipment provided with appropriate guards?
Yes
No
DNA
2. Do all power tools have the correct shield, guard, or attachments recommended or provided by the manufacturer?
Yes
No
DNA
3. Are portable circular saws equipped with guards above and below the base shoe?
Yes
No
DNA
4. Are all cord-connected, electrically operated tools and equipment effectively grounded or have the approved double-insulated type cord?
Yes
No
DNA
5. Are effective guards in place over all belts, pulleys, chains, sprockets, and nip points?
Yes
No
DNA
6. Are portable cooling fans equipped with concentric ring or mesh guards having no opening larger than 0.5 inches?
Yes
No
DNA
7. Are ground fault circuit interrupters installed on all temporary electrical 15 or 20 amp cicuits?
Yes
No
DNA
8. Are pneumatic and hydraulic hoses on power-operated tools in good working condition?
Yes
No
DNA
9. Are pneumatic tools required to be operated at the recommended PSI level?
Yes
No
DNA
Abrasive Wheel Equipment and Grinders
Abrasive Wheel Equipment and Grinders
1. Are work rests used and are they kept adjusted to within 1/8 inch of the wheel?
Yes
No
DNA
2. Are adjustable tongue guards installed and kept adjusted to within 1/4 inch of the wheel?
Yes
No
DNA
3. Do side guards cover the spindle, nut, flange, and 75% of the wheel diameter?
Yes
No
DNA
4. Are bench and pedestal grinders permanently mounted or anchored?
Yes
No
DNA
5. Are new abrasive wheels inspected or ring tested prior to use?
Yes
No
DNA
6. Are grinding wheels required to be used within the recommended RPM rating?
Yes
No
DNA
Machine Guarding
Machine Guarding
1. Is there a training program to instruct current employees and new employees on safe methods of machine operation?
Yes
No
DNA
2. Is equipment and machinery securely mounted or anchored to prevent movement or tipping?
Yes
No
DNA
3. Are emergency stop buttons accessible and clearly identified?
Yes
No
DNA
4. Are foot switches and treadles equipped with guards to prevent unintended operation?
Yes
No
DNA
5. Are all points of operation, in-running nip points, rotating parts, and power transmission hazards protected by rigid guards?
Yes
No
DNA
6. Are provisions made to prevent equipment from automatically starting after power is restored following power interruptions or shutdowns?
Yes
No
DNA
7. Are table saws equipped with blade guards, spreader bars, and anti-kickback devices?
Yes
No
DNA
8. Are radial arm saws equipped with upper and lower blade guards, anti-kickback devices, and will the head gently return to the back of the table when released?
Yes
No
DNA
Electrical
Electrical
1. Are multiple plug (octopus) adapters prohibited?
Yes
No
DNA
2. Are cords with frayed or deteriorated insulation repaired or replaced promptly?
Yes
No
DNA
3. Are flexible cords free of splices or taps?
Yes
No
DNA
4. Are all electrical switches, circuit breakers, and disconnects properly identified to indicate their use and the equipment that each controls?
Yes
No
DNA
5. Are all energized parts of electrical circuits and equipment guarded against accidental contact by approved cabinets or enclosures?
Yes
No
DNA
6. Is there a 3-ft clear space maintained in front of all electrical control cabinets or enclosures?
Yes
No
DNA
7. Are all unused openings and knockouts in electrical enclosures and fittings closed with appropriate covers, plugs, or plates?
Yes
No
DNA
8. Are only heavy duty cords used where exposed to potential damage?
Yes
No
DNA
9. Is ground fault circuit interrupter protection available on all 15 and 20 amp receptacle outlets where flexible cords can be plugged into for use outdoors or where exposed to water or physical damage?
Yes
No
DNA
Lockout/Tagout Procedures
Lockout/Tagout Procedures
1. Is there a formal, written lockout/tagout procedure for powered equipment during setup, maintenance, and servicing?
Yes
No
DNA
2. Are there a sufficient number of locks and tags for any reasonably foreseeable repair or maintenance activity?
Yes
No
DNA
Welding, Cutting, and Brazing
Welding, Cutting, and Brazing
1. Are only trained and authorized employees allowed to use welding, cutting and brazing equipment?
Yes
No
DNA
2. Are compressed gas cylinders inspected for any obvious defects, deep rusting, or leakage on a regular basis?
Yes
No
DNA
3. Are only Compressed Gas Association (CGA) approved accessories (torches, regulators, hoses, etc.) used?
Yes
No
DNA
4. Are compressed gas cylinders secured with chains or substantial racking to prevent tipping and valve damage?
Yes
No
DNA
5. Are compressed gas cylinders protected from excessive heat sources?
Yes
No
DNA
6. Are compressed gas cylinders legibly marked to identify their contents?
Yes
No
DNA
7. Are compressed gas cylinders stored and used only in an upright position?
Yes
No
DNA
8. Are fuel and oxygen cylinders separated by a 20 foot distance or a non-combustible barrier at least 5 feet high?
Yes
No
DNA
9. Are regulators removed, valves closed, and caps in place and properly secured during transport?
Yes
No
DNA
10. Are hose lines color-coded (red for fuel, green for oxygen, and black for inert gases)?
Yes
No
DNA
11. Is appropriate fire fighting equipment available for immediate use?
Yes
No
DNA
12. Are non-combustible screens, shields, or curtains used where needed to prevent ignition of adjacent materials?
Yes
No
DNA
13. Is adequate local or source ventilation provided to exhaust welding or cutting fumes?
Yes
No
DNA
14. Is appropriate personal protective equipment such as aprons, helmets, goggles, respirators, etc. required to be used when needed?
Yes
No
DNA
15. Do you have a first aid kit set up to specifically address burn injuries?
Yes
No
DNA
Compressors and Compressed Air
Compressors and Compressed Air
1. Are compressors equipped with pressure relief valves and pressure gauges?
Yes
No
DNA
2. Are over-pressure relief devices in proper operating order?
Yes
No
DNA
3. Are belt-drive and pulley systems fully enclosed on four sides with rigid guards having no openings greater than 1/2 inch?
Yes
No
DNA
Hoisting Equipment
Hoisting Equipment
1. Is each overhead electric hoist equipped with upper and lower limit switches?
Yes
No
DNA
2. Will each hoist automatically stop and hold a load of up to 125% of its rated capacity when the actuating force is removed?
Yes
No
DNA
3. Is the rated load capacity of each hoist clearly marked and visible to the operator?
Yes
No
DNA
4. Are trolley hoists equipped with end stops to limit travel?
Yes
No
DNA
5. Are hoist controls clearly marked to indicate the direction of travel or motion?
Yes
No
DNA
6. Are hoist ropes, cables, or chains of sufficient length to maintain two full wraps on the drum at all times?
Yes
No
DNA
7. Are kinked or damaged chokers, slings, or hoist ropes removed from service and discarded?
Yes
No
DNA
8. Are all load hooks equipped with safety gates or latches to prevent loads from coming uncoupled or unconnected?
Yes
No
DNA
9. Are hoists and lifting apparatus inspected by a qualified individual at regular intervals?
Yes
No
DNA
10. Is documentation of regular and frequent inspections available?
Yes
No
DNA
11. Is there any evidence of kinked or frayed cables?
Yes
No
DNA
Powered Industrial Trucks and Forklifts/Heavy Equipment
Powered Industrial Trucks and Forklifts/Heavy Equipment
1. Are only trained personnel allowed to operate heavy equipment?
Yes
No
DNA
2. Is substantial overhead protection provided on high-lift rider equipment?
Yes
No
DNA
3. Are forklift operating rules established, posted, and enforced?
Yes
No
DNA
4. Is directional lighting (front and rear) provided on each forklift that operates in darkened areas?
Yes
No
DNA
5. Do all forklifts have a horn and audible or illuminated backup alarms?
Yes
No
DNA
6. Do operators conduct a daily pre-use safety check of their equipment (trucks, plows, graders, forklifts, etc...)?
Yes
No
DNA
Storage
Storage
1. Are flammable liquids properly stored and identified?
Yes
No
DNA
2. Are no smoking signs posted throughout the shop and near flammable materials?
Yes
No
DNA
Occupational Noise Exposure
Occupational Noise Exposure
1. Are employees allowed to select from a variety of hearing protectors that help reduce the noise exposure?
Yes
No
DNA
2. Are employees trained on the purpose, advantages, disadvantages, effectiveness, and use of hearing protective devices while working in the shop and when operating heavy equipment?
Yes
No
DNA
Hazard Communication "Right-to-Know"
Hazard Communication "Right-to-Know"
1. Is there a list of all hazardous substances used or stored in the facility?
Yes
No
DNA
2. Is a current Safety Data Sheet (SDS) readily available for each chemical or substance included in the master list?
Yes
No
DNA
3. Are SDS's accessible and available to all employees with routine or emergency exposures?
Yes
No
DNA
4. Are all containers of hazardous substances (vats, silos, drums, bottles, cans, etc.) clearly marked as to their contents, safety hazards, and precautions to be followed by employees?
Yes
No
DNA
5. Are all employees required to participate in documented initial and annual refresher training on hazardous chemicals they may be exposed to in the workplace and in the entire Hazard Communication Program?
Yes
No
DNA
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