Office/Shop/Yard Inspection
Information about the person completing this form:
Full Name:
*
First Name
Last Name
Phone Number:
*
-
Area Code
Phone Number
Job Title:
E-mail Address:
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Date You Are Completing Inspection:
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Month
-
Day
Year
Date
Work Location Inspected:
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Office
Shop
Yard
Work Location Address/ LSD:
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Items to Inspect:
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Inspected
(No Deficiencies Found)
Inspected
(Deficiency/Haz Found)
N/A
(No item to be inspected)
Windows, Floors, Doors & Stairs
Work Surfaces
(desk tops, work benches, various work stations)
Lighting, including emergency lighting
Electrical Wiring, Cords
(check for fraying or exposed wires, any other signs indicating repair necessary)
Exits
(must be clear of obstructions, and exits clearly marked)
Emergency Response Plan
(is it posted an do workers know what to do in the event of an emergency?)
Fire Protection Equipment
Heating and Cooling
Sanitation
Ventilation
(there should be no obstructions near ventilation areas)
WHMIS and SDS
(worksites need to have information on any hazardous materials available)
Flammable Liquids and Gases
(must be stored according to manufacturer recommendations)
Hand and Power Tools
(Specs and manuals should be available at the worksite. All safety guards should be in place and in good condition)
Ladders
Vehicles
(Complete a walk around inspection of any forklifts, skid steers, vehicles. Are the tires, alarm etc in good condition?)
First Aid Kits
PPE
(Staff need to be wearing appropriate PPE, in good condition and worn properly)
Safe Job Procedures
(Are procedures and practices being followed according to site rules?)
Proper Lifting
(Are proper lifting techniques being followed? Are tools and equipment available to use for heavy loads)
Housekeeping
Maintenance
(Are maintenance records, or indication of last servicing readily available?)
Safety Training
(Do workers on site have their appropriate safety training and proof of training?)
Smoking/Vaping
(Are designated smoking sections marked and being adhered to?)
Storage Areas
(Storage areas tidy? Heavy items stored on bottom shelves? Top shelves secure?)
Health and Safety Committee/Rep Information
(Is the name and contact info for the applicable persons available?)
Health and Safety Meeting Minutes
(Are the meeting minutes posted from the previous H&S Committee meeting posted in a common area?)
Calculation:
For all items inspected and deficiency/hazard identified, please complete the following:
Windows/Floors/Doors & Stairs Deficiencies:
Deficiency/Hazard Observed
Location of Hazard
Controls to mitigate, reduce or remove the hazard?
Who is responsible for Implementing the control?
Due Date (MMDDYY)
Please Describe
What is the level of PRIORITY to fix this hazard?
*
LOW- Manage for Continuous Improvement
MEDIUM- Incorporate Risk Reduction Measures
HIGH- Intolerable
Work Surfaces Deficiencies:
Deficiency/Hazard Observed
Location of Hazard
Controls to mitigate, reduce or remove the hazard?
Who is responsible for Implementing the control?
Due Date (MMDDYY)
Please Describe
What is the level of PRIORITY to fix this hazard?
*
LOW- Manage for Continuous Improvement
MEDIUM- Incorporate Risk Reduction Measures
HIGH- Intolerable
Lighting Deficiencies:
Deficiency/Hazard Observed
Location of Hazard
Controls to mitigate, reduce or remove the hazard?
Who is responsible for Implementing the control?
Due Date (MMDDYY)
Please Describe
What is the level of PRIORITY to fix this hazard?
*
LOW- Manage for Continuous Improvement
MEDIUM- Incorporate Risk Reduction Measures
HIGH- Intolerable
Electrical wiring, cords deficiencies:
Deficiency/Hazard Observed
Location of Hazard
Controls to mitigate, reduce or remove the hazard?
Who is responsible for Implementing the control?
Due Date (MMDDYY)
Please Describe
What is the level of PRIORITY to fix this hazard?
*
LOW- Manage for Continuous Improvement
MEDIUM- Incorporate Risk Reduction Measures
HIGH- Intolerable
Exits, alarms deficiencies:
Deficiency/Hazard Observed
Location of Hazard
Controls to mitigate, reduce or remove the hazard?
Who is responsible for Implementing the control?
Due Date (MMDDYY)
Please Describe
What is the level of PRIORITY to fix this hazard?
*
LOW- Manage for Continuous Improvement
MEDIUM- Incorporate Risk Reduction Measures
HIGH- Intolerable
Emergency Response Plan deficiencies:
Deficiency/Hazard Observed
Location of Hazard
Controls to mitigate, reduce or remove the hazard?
Who is responsible for Implementing the control?
Due Date (MMDDYY)
Please Describe
What is the level of PRIORITY to fix this hazard?
*
LOW- Manage for Continuous Improvement
MEDIUM- Incorporate Risk Reduction Measures
HIGH- Intolerable
Fire protection equipment deficiencies:
Deficiency/Hazard Observed
Location of Hazard
Controls to mitigate, reduce or remove the hazard?
Who is responsible for Implementing the control?
Due Date (MMDDYY)
Please Describe
What is the level of PRIORITY to fix this hazard?
*
LOW- Manage for Continuous Improvement
MEDIUM- Incorporate Risk Reduction Measures
HIGH- Intolerable
Heating and cooling deficiencies:
Deficiency/Hazard Observed
Location of Hazard
Controls to mitigate, reduce or remove the hazard?
Who is responsible for Implementing the control?
Due Date (MMDDYY)
Please Describe
What is the level of PRIORITY to fix this hazard?
*
LOW- Manage for Continuous Improvement
MEDIUM- Incorporate Risk Reduction Measures
HIGH- Intolerable
Sanitation deficiencies:
Deficiency/Hazard Observed
Location of Hazard
Controls to mitigate, reduce or remove the hazard?
Who is responsible for Implementing the control?
Due Date (MMDDYY)
Please Describe
What is the level of PRIORITY to fix this hazard?
*
LOW- Manage for Continuous Improvement
MEDIUM- Incorporate Risk Reduction Measures
HIGH- Intolerable
Ventilation deficiencies:
Deficiency/Hazard Observed
Location of Hazard
Controls to mitigate, reduce or remove the hazard?
Who is responsible for Implementing the control?
Due Date (MMDDYY)
Please Describe
What is the level of PRIORITY to fix this hazard?
*
LOW- Manage for Continuous Improvement
MEDIUM- Incorporate Risk Reduction Measures
HIGH- Intolerable
WHMIS and SDS deficiencies:
Deficiency/Hazard Observed
Location of Hazard
Controls to mitigate, reduce or remove the hazard?
Who is responsible for Implementing the control?
Due Date (MMDDYY)
Please Describe
What is the level of PRIORITY to fix this hazard?
*
LOW- Manage for Continuous Improvement
MEDIUM- Incorporate Risk Reduction Measures
HIGH- Intolerable
Flammable liquids and gasses deficiencies:
Deficiency/Hazard Observed
Location of Hazard
Controls to mitigate, reduce or remove the hazard?
Who is responsible for Implementing the control?
Due Date (MMDDYY)
Please Describe
What is the level of PRIORITY to fix this hazard?
*
LOW- Manage for Continuous Improvement
MEDIUM- Incorporate Risk Reduction Measures
HIGH- Intolerable
Hand and power tool deficiencies:
Deficiency/Hazard Observed
Location of Hazard
Controls to mitigate, reduce or remove the hazard?
Who is responsible for Implementing the control?
Due Date (MMDDYY)
Please Describe
What is the level of PRIORITY to fix this hazard?
*
LOW- Manage for Continuous Improvement
MEDIUM- Incorporate Risk Reduction Measures
HIGH- Intolerable
Ladder deficiencies:
Deficiency/Hazard Observed
Location of Hazard
Controls to mitigate, reduce or remove the hazard?
Who is responsible for Implementing the control?
Due Date (MMDDYY)
Please Describe
What is the level of PRIORITY to fix this hazard?
*
LOW- Manage for Continuous Improvement
MEDIUM- Incorporate Risk Reduction Measures
HIGH- Intolerable
Vehicle/Equipment deficiencies:
Deficiency/Hazard Observed
Location of Hazard
Controls to mitigate, reduce or remove the hazard?
Who is responsible for Implementing the control?
Due Date (MMDDYY)
Please Describe
What is the level of PRIORITY to fix this hazard?
*
LOW- Manage for Continuous Improvement
MEDIUM- Incorporate Risk Reduction Measures
HIGH- Intolerable
First Aid Kit deficiencies:
Deficiency/Hazard Observed
Location of Hazard
Controls to mitigate, reduce or remove the hazard?
Who is responsible for Implementing the control?
Due Date (MMDDYY)
Please Describe
What is the level of PRIORITY to fix this hazard?
*
LOW- Manage for Continuous Improvement
MEDIUM- Incorporate Risk Reduction Measures
HIGH- Intolerable
PPE deficiencies:
Deficiency/Hazard Observed
Location of Hazard
Controls to mitigate, reduce or remove the hazard?
Who is responsible for Implementing the control?
Due Date (MMDDYY)
Please Describe
What is the level of PRIORITY to fix this hazard?
*
LOW- Manage for Continuous Improvement
MEDIUM- Incorporate Risk Reduction Measures
HIGH- Intolerable
Deficiencies with Safe Job Procedures:
Deficiency/Hazard Observed
Location of Hazard
Controls to mitigate, reduce or remove the hazard?
Who is responsible for Implementing the control?
Due Date (MMDDYY)
Please Describe
What is the level of PRIORITY to fix this hazard?
*
LOW- Manage for Continuous Improvement
MEDIUM- Incorporate Risk Reduction Measures
HIGH- Intolerable
Deficiencies with proper lifting techniques:
Deficiency/Hazard Observed
Location of Hazard
Controls to mitigate, reduce or remove the hazard?
Who is responsible for Implementing the control?
Due Date (MMDDYY)
Please Describe
What is the level of PRIORITY to fix this hazard?
*
LOW- Manage for Continuous Improvement
MEDIUM- Incorporate Risk Reduction Measures
HIGH- Intolerable
Housekeeping deficiencies:
Deficiency/Hazard Observed
Location of Hazard
Controls to mitigate, reduce or remove the hazard?
Who is responsible for Implementing the control?
Due Date (MMDDYY)
Please Describe
What is the level of PRIORITY to fix this hazard?
*
LOW- Manage for Continuous Improvement
MEDIUM- Incorporate Risk Reduction Measures
HIGH- Intolerable
Maintenance documentation deficiencies:
Deficiency/Hazard Observed
Location of Hazard
Controls to mitigate, reduce or remove the hazard?
Who is responsible for Implementing the control?
Due Date (MMDDYY)
Please Describe
What is the level of PRIORITY to fix this hazard?
*
LOW- Manage for Continuous Improvement
MEDIUM- Incorporate Risk Reduction Measures
HIGH- Intolerable
Safety Training/tickets deficiencies:
Deficiency/Hazard Observed
Location of Hazard
Controls to mitigate, reduce or remove the hazard?
Who is responsible for Implementing the control?
Due Date (MMDDYY)
Please Describe
What is the level of PRIORITY to fix this hazard?
*
LOW- Manage for Continuous Improvement
MEDIUM- Incorporate Risk Reduction Measures
HIGH- Intolerable
Smoking area deficiencies:
Deficiency/Hazard Observed
Location of Hazard
Controls to mitigate, reduce or remove the hazard?
Who is responsible for Implementing the control?
Due Date (MMDDYY)
Please Describe
What is the level of PRIORITY to fix this hazard?
*
LOW- Manage for Continuous Improvement
MEDIUM- Incorporate Risk Reduction Measures
HIGH- Intolerable
Storage area deficiencies:
Deficiency/Hazard Observed
Location of Hazard
Controls to mitigate, reduce or remove the hazard?
Who is responsible for Implementing the control?
Due Date (MMDDYY)
Please Describe
What is the level of PRIORITY to fix this hazard?
*
LOW- Manage for Continuous Improvement
MEDIUM- Incorporate Risk Reduction Measures
HIGH- Intolerable
Health and Safety Committee Information Deficiencies:
Deficiency/Hazard Observed
Location of Hazard
Controls to mitigate, reduce or remove the hazard?
Who is responsible for Implementing the control?
Due Date (MMDDYY)
Please Describe
What is the level of PRIORITY to fix this hazard?
*
LOW- Manage for Continuous Improvement
MEDIUM- Incorporate Risk Reduction Measures
HIGH- Intolerable
Any additional comments?
Please sign off that all above information is complete and accurate:
*
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