Work Site Inspection Form
Employee Information
What Is Your Name?
*
First Name
Last Name
What Is Your Email Address?
*
example@example.com
Today's Date
*
-
Month
-
Day
Year
Date
Please Select Your Office
*
Please Select
Grand Rapids (Alpine)
Grand Rapids (Cascade)
Grandville
Holland
Muskegon (Norton Shores)
Livonia
Warren
Indianapolis
Fort Wayne
Elkhart
Goshen
South Bend
Client Information
Client's Name
*
Client's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Client's Worksite Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client Representative
First Name
Last Name
Date of Site Evaluation
*
-
Month
-
Day
Year
Date
Worksite Workers Comp Code(s)
*
Brief Description of Client's Operation
List The Positions, Descriptions of Duties, and PPE Required For Assignments Covered By This Survey
Rows
Position
Job Description
PPE Required
Position 1
Position 2
Position 3
Accident History
Review Client's OSHA 300 Log and/or Other Records of Job Injuries and Determine the Following:
Total Number of Injuries in The Last 12 Months?
*
Total Number of Injuries Resulting in Lost Time?
*
Describe Severe Accidents and/or Steps Implemented by Client To Prevent Accident Recurrence(s):
Client Safety Program Elements
Client Safety/Training Programs should include Forge Employees. Determine Those Elements of Client Programs That Forge Employees Will Particpate In:
Written Safety Policy
NO
YES
Explain
Explain Your Answer Regarding The Written Safety Policy
Corrective Action
Explain The Corrective Action Regarding The Written Safety Policy
Timeline
Explain The Timeline Regarding The Written Safety Policy
General Safety Orientation
NO
YES
Explain
Explain Your Answer Regarding The Written Safety Policy
Corrective Action
Explain The Corrective Action Regarding The Written Safety Policy
Timeline
Explain The Timeline Regarding The Written Safety Policy
Job-Specific Training
NO
YES
Explain
Corrective Action
Timeline
Periodic Safety Inspections
NO
YES
Explain
Explain Your Answer Regarding The Written Safety Policy
Corrective Action
Explain The Corrective Action Regarding The Written Safety Policy
Timeline
Explain The Timeline Regarding The Written Safety Policy
Safety Committee
NO
YES
Explain
Explain Your Answer Regarding The Written Safety Policy
Corrective Action
Explain The Corrective Action Regarding The Written Safety Policy
Timeline
Explain The Timeline Regarding The Written Safety Policy
Evacuation Plan
NO
YES
Explain
Explain Your Answer Regarding The Written Safety Policy
Corrective Action
Explain The Corrective Action Regarding The Written Safety Policy
Timeline
Explain The Timeline Regarding The Written Safety Policy
HAZCOM Training
NO
YES
Explain
Explain Your Answer Regarding The Written Safety Policy
Corrective Action
Explain The Corrective Action Regarding The Written Safety Policy
Timeline
Explain The Timeline Regarding The Written Safety Policy
Ongoing Safety Training
NO
YES
Explain
Explain Your Answer Regarding The Written Safety Policy
Corrective Action
Explain The Corrective Action Regarding The Written Safety Policy
Timeline
Explain The Timeline Regarding The Written Safety Policy
Written Disciplinary Procedure
NO
YES
Explain
Explain Your Answer Regarding The Written Safety Policy
Corrective Action
Explain The Corrective Action Regarding The Written Safety Policy
Timeline
Explain The Timeline Regarding The Written Safety Policy
First Aid-Medical Facilities
Does client have on-site medical facilities available to Forge Employees?
*
Yes
No
Does client have arrangements with a clinic in the area?
*
Yes
No
Name of client's clinic
Address of client's clinic
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Designated Clinic for Forge Employees?
Site Evaluation
Are work areas reasonably neat, clean, and free of debris?
NO
YES
Explain
Explain Your Answer Regarding The Written Safety Policy
Corrective Action
Explain The Corrective Action Regarding The Written Safety Policy
Timeline
Explain The Timeline Regarding The Written Safety Policy
Is there proper lighting in the work areas?
NO
YES
Explain
Explain Your Answer Regarding The Written Safety Policy
Corrective Action
Explain The Corrective Action Regarding The Written Safety Policy
Timeline
Explain The Timeline Regarding The Written Safety Policy
Is access to fire exits clear of walls and/or debris?
NO
YES
Explain
Explain Your Answer Regarding The Written Safety Policy
Corrective Action
Explain The Corrective Action Regarding The Written Safety Policy
Timeline
Explain The Timeline Regarding The Written Safety Policy
Are workers exposed to excessive noise?
NO
YES
Explain
Explain Your Answer Regarding The Written Safety Policy
Corrective Action
Explain The Corrective Action Regarding The Written Safety Policy
Timeline
Explain The Timeline Regarding The Written Safety Policy
Are machines guarded properly?
NO
YES
Explain
Explain Your Answer Regarding The Written Safety Policy
Corrective Action
Explain The Corrective Action Regarding The Written Safety Policy
Timeline
Explain The Timeline Regarding The Written Safety Policy
Is jewelry allowed to be worn?
NO
YES
Explain
Explain Your Answer Regarding The Written Safety Policy
Corrective Action
Explain The Corrective Action Regarding The Written Safety Policy
Timeline
Explain The Timeline Regarding The Written Safety Policy
Are there sharp objects that could cause injury?
NO
YES
Explain
Explain Your Answer Regarding The Written Safety Policy
Corrective Action
Explain The Corrective Action Regarding The Written Safety Policy
Timeline
Explain The Timeline Regarding The Written Safety Policy
Do workers reach over machinery/moving parts?
NO
YES
Explain
Explain Your Answer Regarding The Written Safety Policy
Corrective Action
Explain The Corrective Action Regarding The Written Safety Policy
Timeline
Explain The Timeline Regarding The Written Safety Policy
Are workers performing repetitive tasks?
NO
YES
Explain
Explain Your Answer Regarding The Written Safety Policy
Corrective Action
Explain The Corrective Action Regarding The Written Safety Policy
Timeline
Explain The Timeline Regarding The Written Safety Policy
Is accessible fire protection properly designated?
NO
YES
Explain
Explain Your Answer Regarding The Written Safety Policy
Corrective Action
Explain The Corrective Action Regarding The Written Safety Policy
Timeline
Explain The Timeline Regarding The Written Safety Policy
Are workers exposed to electrical hazards?
NO
YES
Explain
Explain Your Answer Regarding The Written Safety Policy
Corrective Action
Explain The Corrective Action Regarding The Written Safety Policy
Timeline
Explain The Timeline Regarding The Written Safety Policy
Is adequate ventilation provided?
NO
YES
Explain
Explain Your Answer Regarding The Written Safety Policy
Corrective Action
Explain The Corrective Action Regarding The Written Safety Policy
Timeline
Explain The Timeline Regarding The Written Safety Policy
Are employees working more than 4 feet off of the ground? If Yes, what safety measures are in place and what approvals are being sought?
NO
YES
Explain
Explain Your Answer Regarding The Written Safety Policy
Corrective Action
Explain The Corrective Action Regarding The Written Safety Policy
Timeline
Explain The Timeline Regarding The Written Safety Policy
Is the company Following CDC guidelines?
*
NO
YES
Explain
Explain Your Answer Regarding The Written Safety Policy
Corrective Action
Explain The Corrective Action Regarding The Written Safety Policy
Timeline
Explain The Timeline Regarding The Written Safety Policy
Additional Notes
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