General Safety Inspection Form
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AM/PM Option
Submitted By
*
David Rankin
Ivan Pendergast
Ozzie Crespo
Space Information
Building
Building 2
Room/Space Name
Type of Space
Please Select
Lab
Classroom
Hallway
Lecture Hall
Mechanical Room
Office
Common Area
Outside
Room Number
Submit
Reason for Submission.
*
General Work Environment Inspection
Ladder Inspection
Hazardous Material Inspection
Flammable and Compressed Gas Cylinders Inspection
Personal Protective Equipment
Emergency Equipment and Egress Inspection
Monthly Fire Extinguisher Inspection
Annual Fire Extinguisher Inspections
AED Inspection
Electrical Safety Inspection
Issue Submission Only
Building Completed
General Work Environment Inspection Section
Housekeeping-work areas clean and orderly
Yes
No
N/A
Housekeeping-floor clean and dry with no trip hazards
Yes
No
N/A
Housekeeping-building materials in good condition w/no hazards noticed
Yes
No
N/A
Housekeeping-storage shelves/racks stable and material stored safely
Yes
No
N/A
Floors and elevated surfaces without unprotected holes or edges
Yes
No
N/A
Holes and Openings in floor properly covered and guarded
Yes
No
N/A
Proper/effective workplace hazard controls in place
Yes
No
N/A
Other General Work Environment Items
Submit
Clear Form
Collapse Stopper.
Ladder Inspection Section
Portable ladders free of sharp edges, cracks, splinters, foreign substances, broken, loose or missing parts, and maintained in good, working order
Yes
No
N/A
Ladder manufacturer's labels with rating information present and legible
Yes
No
N/A
Portable ladders do not exceed 20ft
Yes
No
N/A
Other Ladder Items
Submit
Clear Form
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Hazardous Material Inspection Section
Chemical containers, including secondary containers and stationary/piping systems, have legible, original or OSHA-compliant labels
Yes
No
N/A
Corrosives stored below eye level
Yes
No
N/A
Chemical containers closed when not in use
Yes
No
N/A
Oily rag waste stored in covered metal cans
Yes
No
N/A
Chemicals stored near sinks/drains protected with secondary containment
Yes
No
N/A
Secondary containment bins compliant: no incompatible chemicals; able to contain 110% of the volume of the largest container
Yes
No
N/A
Hazardous waste labeled as "Hazardous Waste" with full chemical names
Yes
No
N/A
Hazardous waste containers in good condition with tight-fitting caps/lids
Yes
No
N/A
Designated hazwaste storage areas labeled “Satellite Accumulation Area”
Yes
No
N/A
Volume of total hazwaste is less then 55 gallons and less then 1 quart “acutely hazardous”
Yes
No
N/A
Incompatible wastes properly segregated (e.g., secondary containment bins)
Yes
No
N/A
CFLs stored and labeled properly (Universal Waste w/accumulation date)
Yes
No
N/A
Other Hazardous Waste observations in compliance
Submit
Clear Form
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Flammables and Compressed Gas Inspection Section
Flammables in excess of 30 gallons stored in rated flammable cabinet/refrigerator
Yes
No
N/A
Flammable storage areas labeled as such or with a red flammable diamond sticker
Yes
No
N/A
Flammables/aerosol cans stored away from heat/ignition sources
Yes
No
N/A
Flammables liquids stored separately from incompatible materials
Yes
No
N/A
Compressed Gas Cylinders—stored upright in well-ventilated area; individually fastened or secured in cage)
Yes
No
N/A
Compressed Gas Cylinders—cap or regulator in place
Yes
No
N/A
Compressed Gas Cylinders—labeled and stored so label can be easily read
Yes
No
N/A
Compressed Gas Cylinders—valves accessible
Yes
No
N/A
Compressed Gas Cylinders— kept away from ignition sources
Yes
No
N/A
Compressed Gas Cylinders— incompatible gases (e.g., O2 & acetylene) stored ≥20 ft. apart or separated by ≥5 ft. high firewall with ½ hour fire rating
Yes
No
N/A
Compressed Gas Cylinders— empty and full cylinders stored separately
Yes
No
N/A
Compressed Gas Cylinders— secured while transported
Yes
No
N/A
Procedures to address chemical spills in place and communicated with employees
Yes
No
N/A
Other Hazardous Material observations?
Submit
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PPE Inspection Section
PPE is made available
Yes
No
N/A
PPE maintained in sanitary and reliable condition
Yes
No
N/A
Appropriate eye and face protection used
Yes
No
N/A
Appropriate head protection used
Yes
No
N/A
Appropriate foot protection used
Yes
No
N/A
Appropriate hand protection used
Yes
No
N/A
Appropriate body protection used
Yes
No
N/A
Appropriate Electrical PPE and Protective Clothing used
Yes
No
N/A
Appropriate respiratory protection used
Yes
No
N/A
Respirator wearers are medically evaluated, trained and fit-tested, as applicable
Yes
No
N/A
Appropriate hearing protection used
Yes
No
N/A
Employees with noise overexposures sent for audiometric testing and training
Yes
No
N/A
Other PPE observations
Submit
Clear Form
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Emergency Equipment and Egress Section
Worksites with corrosives have proper emergency eyewash/shower equipment
Yes
No
N/A
Eyewash/shower stations within 10 seconds or 100 ft. of uninterrupted walk
Yes
No
N/A
Plumbed eyewash stations tested weekly
Yes
No
N/A
Fire extinguishers and alarms accessible and unobstructed
Yes
No
N/A
Sprinkler systems have 18 inch vertical and horizontal clearance zones
Yes
No
N/A
Exit doors unlocked and unobstructed
Yes
No
N/A
Exits marked with readily visible signs
Yes
No
N/A
Routes of egress (exits, aisles, hallways and stairways) free of obstructions
Yes
No
N/A
Other Emergency Equipment & Egress observations in compliance
Submit
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Monthly Fire Extinguisher Inspection Section
Checked for proper dates on Fire Extinguisher tags?
Yes
No
N/A
Checked for proper indication on Fire Extinguisher pressure gauge?
Yes
No
N/A
Checked Fire Extinguisher pin and safety strap?
Yes
No
N/A
Checked Fire Extinguisher nozzle for powder residue?
Yes
No
N/A
Checked Fire Extinguisher for visable damage?
Yes
No
N/A
Number of Fire Extinguishers inspected.
Number of Fire Extinguishers needing service
Notes for Monthly Fire Extinguisher Inspections
Submit
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Annual Fire Extinguisher Inspection Section
Number of Fire Extinguisher receiving Annual Inspection
Number of Fire Extinguisher receiving 6 year service
Number of Fire Extinguisher receiving 12 year Hydro
Number of Fire Extinguisher receiving recharging
Notes for Annual Fire Extinguisher Inspection
Submit
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AED Inspection Section.
Completed AED self-check by depressing on button for 5 seconds?
Yes
No
N/A
Checked expiration date on AED pads?
Yes
No
N/A
Visually checked outside of AED pad packaging for damage?
Yes
No
N/A
Checked that the cable for the AED pad is securely connected to AED unit?
Yes
No
N/A
Visually checked the AED unit for damage
Yes
No
N/A
Number of AED inspection completed in this space
Notes for AED inspections
Submit
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Electrical Safety Inspection Section.
Employees know the location of electrical panels/disconnect switches/e-stops
Yes
No
N/A
Circuit breakers labeled properly
Yes
No
N/A
Electrical panels/disconnect switches/e-stops unobstructed; 3 ft clearance maintained in front of electrical panels
Yes
No
N/A
Electrical boxes have covers in place and not damaged
Yes
No
N/A
Electrical cords in good condition—no damaged insulation, exposed wires or missing ground pins
Yes
No
N/A
Electrical cords’ use, size and rating appropriate for usage and environment
Yes
No
N/A
Extension cords used only on a temporary basis
Yes
No
N/A
Multi-tap power strips are used long-term only with computer or electronic equipment
Yes
No
N/A
Extension cords are not linked together (daisy-chaining).
Yes
No
N/A
Electrical cords do not run through doors, walls or partitions, under rugs, or above drop ceilings; they are not tied in knots, draped overhead, or attached to building structures
Yes
No
N/A
Electrical circuits not overloaded
Yes
No
N/A
Electrical equipment not in wet/damp locations, unless rated as such
Yes
No
N/A
Live parts effectively insulated or physically guarded
Yes
No
N/A
GFCIs installed near wet environments, as required
Yes
No
N/A
Flammable materials kept away from electrical equipment
Yes
No
N/A
Other Electrical Safety observations in compliance
Submit
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Notes/Action Submission
Notes
Action Taken
Submit Copy to Service-Request@trinity.edu?
Yes
No
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