CITY OF LOS ANGELES
DEPARTMENT NAME
Division Name (If applicable)
INJURY/ILLNESS
PREVENTION PROGRAM
August 2011
INJURY AND ILLNESS PREVENTION PROGRAM
TABLE OF CONTENTS
________________________________________________________________________________________________________________________
Topic
Page No.
Policy Statement …………………………………………………………………………………….
1
Introduction……………………………………………………………………………………………
2
1. Safety Responsibilities …………………………………………………………………………….
3
2. Safety Communication …………………………………………………………………………....
4
3. Employee Compliance with Safe Work Practices ………………………………………………
5
4. Hazard Assessment and Inspection ……………………………………………………………..
6
5. Accident/Exposure Investigation …………………………………………………………….......
7
6. Hazard Correction ………………………………………………………………………………….
9
7. Training and Instruction …………………………………………………………………………...
10
8. Record Keeping ……………………………………………………………………………………
11
Appendix A – Code Of Safe Practices – Office Areas ………………...…………………………
16
Appendix B – Safety Concern or Suggestion Report ……………………………………………
18
Hazard Removal/Abatement form …………………………………………………
19
Appendix C – Worksheet for Reporting Fatalities/Serious Injury or Illness to Cal/OSHA…….
20
Appendix D – Accident Investigation Form (Example*) ……..………………………………….
21
Employee’s Report of Injury Form .……………………………………………….
22
Accident Witness Statement ………………………………………………………
23
Supervisor Accident Investigation …………………………………………………
24
Appendix E – Training Roster ………………………………………………………………………
25
Appendix F– Facility Inspection Checklists (Example*) …………………………………………
26
* Employees may use this form or develop one of their own which reflects more accurately
the circumstances at their worksite and contains all pertinent information.
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POLICY STATEMENT
It is the policy of the General Manager of the DEPARTMENT/DIVISION that all employees have a
safe place of employment and that all of our work be performed in a manner that provides the highest
level of safety for the protection of department employees and the public. The Head of each division
is also committed to ensuring a safe and healthful workplace. Safety will therefore be given primary
consideration for all work conducted.
Each staff member is expected to recognize his or her responsibility to protect the human, physical
and financial resources of our organization. Accordingly, the DEPARTMENT/DIVISION will make
every effort to comply with applicable Cal/OSHA safety and health regulations, City and department
safety policies, work standards, practices and procedures.
The DEPARTMENT'S/DIVISION’S policy is aimed at minimizing the exposure of our employees to
health and safety risks. To accomplish this objective, work practices and procedures have been
established to help prevent injuries, accidents, illnesses, property damage and releases of hazardous
substances and to help ensure that all employees can do their jobs safely. All employees are
expected to adhere to these safe work practices and procedures and to work diligently to maintain
safe and healthful working conditions.
Supervisors will be accountable for ensuring that equipment and facilities within their areas of
responsibility are maintained in a safe manner. Each employee will be responsible for maintaining
safe working conditions and practices, and complying with safety rules and procedures. The
DEPARTMENT'S/DIVISION’S Injury and Illness Prevention Program is intended to reduce the
frequency of injuries by means of controlling unsafe working conditions and unsafe work practices.
Suggestions for improvements to all of our safety programs including this Injury and Illness
Prevention Program are always encouraged.
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INTRODUCTION
This Injury and Illness Prevention Program (IIPP) is intended to provide guidance for complying with
the safe work principles identified in the California Code of Regulations, Title 8, Section 3203 and for
minimizing employee exposure to safety and health risks at all DEPARTMENT/DIVISION worksites.
The General Manager, ____NAME___________, has the authority and responsibility for
implementing the program (Refer to Mayor’s Executive Directive CP-1). The Safety/Disability
Coordinator,
NAME
is responsible for maintaining the program. Managers, supervisors
and employees are responsible for implementing and adhering to the elements of the program and
providing constructive feedback when applicable. The primary objective of this IIPP is to maintain
a safe and healthy work environment for all DEPARTMENT/DIVISION employees. The IIPP
pursues this objective through the following eight (8) elements:
1.
2.
3.
4.
5.
6.
7.
8.
SAFETY RESPONSIBILITIES
SAFETY COMMUNICATION
EMPLOYEE COMPLIANCE WITH SAFE WORK PRACTICES
HAZARD ASSESSMENT AND INSPECTION
ACCIDENT/EXPOSURE INVESTIGATION
HAZARD CORRECTION
TRAINING AND INSTRUCTION
RECORD KEEPING
A general description of each element is included in the plan along with a bullet point style listing of
responsibilities to expedite the elements implementation.
A copy of this IIPP is available from each Manager, Supervisor, or Safety Coordinator. These
individuals are also available to assist employees in understanding and fulfilling their safety
responsibilities. For assistance, contact the Safety Coordinator at (XXX) XXX-XXXX.
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1. SAFETY RESPONSIBILITIES
Each person at the DEPARTMENT/DIVISION plays an important role in maintaining a safe and
hazard free work environment. To ensure the safety program remains effective, the following
specific responsibilities are required:
All Personnel
 Demonstrate a clear understanding of the IIPP and comply with all safety and health
regulations
 Demonstrate in action and words that safety is a top concern
 Allocate resources as needed to ensure a safe work environment
 Work with managers, supervisors and other employees to continually improve safety within
the department/division
 Maintain a safe and healthy work environment
 Perform work in a safe and responsible manner
Managers
 Oversee the safety responsibilities of the staff, including supervisors, and hold them
accountable for their performance
 Initiate corrective actions when established safety objectives are not achieved
 Take an active, visible role in safety management
 Assign staff the responsibility of providing a safe work environment for employees
 Evaluate the safety performance of management staff and supervisors as part of their annual
evaluation
 Ensure that all required safety equipment is available for use
Supervisors
 Enforce the safety responsibilities of employees and hold them accountable for their
performance
 Evaluate employees’ safety performance as part of their annual evaluation
 Respond to notice of a hazard or unsafe work practice and take the necessary steps to
eliminate the hazard
 Maintain safety training records for employees
 Maintain a current list of hazardous chemicals and the respective Material Safety Data
Sheets (MSDS) for which employees may be exposed.
Employees
 Take an active role in their personal safety and the safety of fellow employees
 Participate in all safety related training
 Provide objective and constructive feedback when established safety objectives need
modification
 Maintain safe working conditions and practices
 Comply with safety rules, regulations and procedures
 Report unsafe conditions or equipment immediately to the Supervisor
Safety Coordinator
 Oversee the IIPP's implementation and maintenance and perform an annual review
for effectiveness
 Advise managers and supervisors of their safety responsibilities and performance
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 Communicate workplace safety and health issues with all employees
 Update the IIPP as necessary and review with management the various safety programs,
policies and procedures
2. SAFETY COMMUNICATION
Communication is an essential element of an effective safety program. Management, supervisors
and employees are encouraged to clearly communicate (and act upon) safety and health
questions or concerns without fear of reprisal. Communication of safety issues is to be in a form
that is readily understandable by all affected employees. Examples of communication tools used
by the DEPARTMENT/DIVISION employees for safety and health related issues include the
following:
 Staff or supervisor meetings where safety is included as an agenda item
 Safety Committee Meetings
 Strategic Planning Teams
 Safety Bulletin Boards (including motivational posters)
 Written programs, policies and procedures
 Safety Tailgate training sessions and meetings
 E-mail
 Intranet
All personnel are expected to be alert and communicate any changes in the workplace that may
result in exposing employees to potential hazards or unsafe conditions. Examples include
changes in work environment, facilities, equipment and work procedures. Periodic division safety
committee meetings take place to increase safety awareness by identifying hazards,
recommending solutions to management and communicating safety concerns to fellow
employees. Typical safety meeting topics include current safety issues, identified hazards and
unsafe conditions, injuries, inspections and safety training and any trends/increases in workers’
comp claims.
Managers and Supervisors
 A safety committee shall be established. The safety committee meeting will consist of
employees representing all levels of management including managers, supervisors, and
employees.
 Ensure that all safety committee meetings where safety and health issues are addressed
occur on a routine basis but not less than quarterly
 Encourage employees to report unsafe conditions and/or near misses and ensure they
understand there will be no reprisal for doing so
 Respond to employee safety concerns in a timely manner
 Review elements of the IIPP, City, and Department policies, programs and procedures with
all employees
 Develop and implement written Standard Operating Procedures (SOP) for unusual or nonroutine hazardous job tasks
Employees
 Attend and actively participate in safety meetings and pertinent safety tailgate sessions
 Provide objective and constructive feedback on safety and health issues
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



Encourage a positive safety culture with fellow employees
Obtain and submit clear and complete information on work limitations
Immediately report all accidents (regardless of severity) to supervisors and complete the
necessary documentation
Notify managers, supervisors and fellow employees of all safety issues that may adversely
affect employees and the work environment
Safety Coordinator
 Provide updates on safety inspections and audits to the Department Head
 Coordinate and facilitate the Safety Committee Meetings
 Ensure that the safety bulletin boards are located in a conspicuous place and keep current
with relevant safety and health information such as:
1. “Safety and Health Protection on the Job” (from Cal/OSHA)
2. “Treatment and Reporting of On-duty Injuries to Civilian Employees”
(Workers Compensation Division, City of L.A. Personnel Department)
3. “Access to Medical and Exposure Records” (Cal/OSHA form S-11)
4. “Emergency phone numbers” (Cal/OSHA form S 500)
5. Responses to corrected unsafe conditions (Hazard Removal/Abatement Form)
6. Motivational safety posters provided by Cal/OSHA
7. Current safety meeting minutes
8. OSHA 300A Log and Summary of Occupational Injuries and Illnesses
(posted from February 1 to April 30 of each year)
Safety Committee
 Meets regularly but not less than quarterly.
 Prepares and makes available to affected employees written records of the safety and health
issues discussed at the committee meetings, and maintained for review upon request.
 Review results of the periodic scheduled worksite inspections.
 Reviews investigations of occupational accidents and causes of incidents resulting in
occupational injury, occupational illness or exposure to hazardous substances, and where
appropriate, submits suggestions to management for the prevention of future incidents.
 Reviews investigations of alleged hazardous conditions brought to the attention of any
committee member. When determined necessary by the committee, it may conduct its own
inspection and investigation to assist in remedial solutions.
 Submits recommendations to assist in the evaluation of employee safety suggestions.
 Verifies abatement action taken to abate citations issued by the OSHA.
3. EMPLOYEE COMPLIANCE WITH SAFE WORK PRACTICES
An effective safety program requires the cooperation and compliance of all
DEPARTMENT/DIVISION employees. Management is responsible for ensuring that all safety and
health policies and procedures are clearly communicated and understood by all employees, and
enforced fairly and uniformly.
Department Managers
 Enforce all Cal/OSHA regulations and City and department safety policies and procedures
 Provide recognition for employees who consistently perform their duties in a safe manner
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Division Supervisors
 Ensure that employees are familiar and comply with the elements of the IIPP, Department
Safety Policies, programs and procedures
 Ensure that both management and employees are aware of the unsafe conditions or hazards
employees may be exposed to and provide them necessary means to perform the task safely
(i.e., training, safety equipment, personal protective equipment, modification of work station
or location, etc.)
 Train employees on the safe work practices and rules applicable to their job tasks and
document this training as a safety tailgate record.
 Ensure that employees are using appropriate personal protective equipment and/or safety
devices.
 Observe and hold employees accountable for their adherence to safety rules and regulations.
 Recognize employees who follow safe work practices in a meeting or written format and
during the annual employee performance evaluation
 Notify and correct employees’ unsafe work behaviors and unsafe acts
 Provide training and/or re-training immediately for employees who demonstrate deficient
safety habits and document this training both in the employees personnel file and as a safety
tailgate record
 Document when/if employees fail to comply with safe work practices, policies or procedures.
Continued failure to comply may result in disciplinary action.
 Ensure that defective tools, equipment and machinery are removed from service and not
used until the hazards can be eliminated
 Ensure that every work assignment is performed with regard for the safety and well being of
employees and that of the public and, if applicable, is in accordance with the written
departmental Standard Operating Procedures
 Rectify any unsafe condition reported that can be corrected by a supervisor
 Perform all “on the job training” in a manner that is consistent with the safe work practices of
the department or division.
Employees
 Understand and adhere to all safety policies, procedures, programs, and codes of safe work
practice
 Understand that adequate safety training is essential to a safe work environment
 Perform all job tasks safely and efficiently and assist co-workers and others in the workplace
to work safely
 Comply with all Federal, State and local laws, rules and regulations governing employee
health and safety
 Comply with manufacturers safety guidelines and rules related to safe use of
equipment and materials
4. HAZARD ASSESSMENT AND INSPECTION
The primary reason for conducting hazard assessments and inspections is to identify and control
hazards, unsafe conditions, and unsafe work practices. Controlling hazards minimizes the risk to
employees and helps to prevent accidents and injuries. This section describes a system for
identifying and evaluating workplace hazards and includes a schedule of periodic inspections.
Examples of hazard assessments include (but not limited to) one or more of the following:

Injury or illness investigations
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



Injury database searches for frequently occurring injuries
Responding to and investigating employee concerns
Monthly, quarterly and annual safety inspections
Near miss incidents and investigations
Material Safety Data Sheets and container label inventory and review
Hazard Assessments and facility inspections are to be conducted when one or more of the following
conditions occur:







When the IIPP is established
When new equipment creates an unsafe condition
When a product, process or procedure creates a hazard or unsafe condition
When a new unrecognized hazard or unsafe condition is identified
When an occupational injury or illness occurs
When a workplace condition warrants an inspection
At least annually
Examples of items that are to be routinely inspected include:






Work sites
Work Facilities (i.e., buildings, trailers, storage areas, shops)
Vehicles
Tools, equipment and machinery
Safety equipment (i.e., SCBA's, monitoring devices, body harnesses, lanyards,
retrieval devices, personal protective equipment)
Emergency equipment (i.e., first aid kits, fire extinguishers, emergency
eyewash/shower stations)
Managers
 Review quarterly inspections reports to ensure the inspections are being effective
 Evaluate workplace inspection records to ensure that any identified hazards are
corrected in a timely manner
Supervisors
 Understand the safety and health hazards to which employees are exposed
 Evaluate worksites on an ongoing basis (daily if possible) for unsafe conditions and take
steps to correct them. The following areas should be included in the evaluation:
1. Physical hazards
2. Generally recognized safe work practices
3. Safety and health problems with employees
4. Employee work habits
5. Use of any hazardous material, chemicals or equipment



Perform regular (at least annually) comprehensive inspections to ensure facilities and
equipment are being safely maintained
Evaluate the inspection program and implement necessary corrective measures to ensure or
improve the program’s effectiveness
Monitor employees to ensure they are complying with safe work practices and performing
their duties in a safe and responsible manner
9



Remind employees of preventive measures to avoid accidents
Take a lead role to minimize and/or eliminate unsafe conditions and practices in the work
place
Document inspections and forward a copy(s) to their manager and Safety Coordinator for
review and action.
Employees
Inspect tools, equipment, machinery, safety equipment, worksite and personal protective
equipment prior to use to identify any items that pose a potential safety risk and notify immediate
supervisor or manager of defective or missing items. Items determined to pose a safety risk are
not to be used until they can be rendered safe and are to be tagged, isolated or removed from
service.
Safety Coordinator
 Review the facilities inspection records to confirm that inspections are taking place in a
competent manner by spot checking field observations
 Track identified concerns or hazards from inspection records until resolved
5.
ACCIDENT/EXPOSURE INVESTIGATION
Accident and exposure (incident) investigations are performed to gather information on the
cause(s) that contributed to their occurrence. This information is useful for determining
corrective actions that can be taken to prevent same type of incident from reoccurring. Events
that are to be investigated include all the work-related injuries and illnesses, vehicle accidents, or
near miss incidents with a potential for significant injury. Investigations are to be documented and
the results communicated to all affected employees.
The DEPARTMENT/DIVISION has the responsibility to investigate all work-related injuries and
illnesses.
Suggested procedures for investigating workplace accidents and hazardous
substance exposure include the following:
 Visit the accident/incident scene as soon as possible
 Interview injured employees and witnesses
 Examine the workplace for factors associated with the accident/incident
 Determine root cause
 Implement corrective actions to prevent reoccurrence
 Record findings and corrective actions
 Take pictures/video of accident scene if possible
 Identify who, what, why, where, and when
Vehicle Accidents - In the event of a work-related accident or incident involving a City of Los
Angeles vehicle, follow the instructions contained in the Vehicle Accident Report envelope that
should be located in the glove compartment. These instructions include completing and
processing the City's Vehicle Accident Report Form Gen. 88 and notifying your supervisor of the
incident by e-mail. The Form Gen. 88 must be completed and submitted to the City Attorney
within 24 hours of the accident. In case of injury, (no matter how slight) or death, report
accident immediately by phone to the City Attorney, Automobile Liability Section at (213) 9787040.
Fatalities/Serious Injury or Illness - These types of incidents must be reported to Cal/OSHA
as soon as practical but not longer than eight (8) hours after knowledge of the fatality,
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serious injury or illness. "Serious injury or illness" is defined as any work related injury or illness
which requires inpatient hospitalization for a period in excess of 24 hours for other than medical
observation, or in which an employee suffers a loss of any member of the body or any serious
degree of permanent disfigurement.
If a work related fatality or serious injury or illness occurs at your facility, implement the following
procedures:
Take care of the injured immediately. If appropriate, call 911.
Immediately call the Personnel Department Safety Section at (213) 473-3373 or (213) 473-3392.
If requested to do so, Call Cal/OSHA to report the injury.
NOTE: The Cal/OSHA representative will ask for the information listed in the Worksheet for
Reporting
Fatalities/Serious Injury or Illness to Cal/OSHA. Do not delay calling if all
required information listed below is not known within the 8-hour notification requirement.
TELEPHONE Department
- (213) XXX-XXXX (Safety Coordinator)
NUMBERS:
Cal/OSHA- (213) 576-7451 (Los Angeles District Office)
Safety Division- (213) 473-3373 (City Safety Administrator)
Department Personnel (XXX) XXX-XXXX (Personnel Director)
Department Head
 Distribute a memorandum to the City Attorney’s office, Workers’ Comp section, and the
Personnel Safety Section in the event of a fatality/serious injury or illness that briefly
describes the incident and confirms that a notification to Cal/OSHA and City Safety
Administrator was made within eight (8) hours of knowledge of the incident. Ensure that
corrective actions are taken to prevent reoccurrence
Managers
 Review forms 5020 and accident investigation form (and any other accident reports) and
maintain records
 Ensure that corrective actions are taken to prevent reoccurrence
 Verify that the Department Manager has been notified of an injury or illness and provide
updates on the status of investigations
Supervisors
 Notify Safety Coordinator and Department Manager by e-mail immediately upon discovery of
an injury or illness. In the event of a fatality or serious injury Cal-OSHA should also be notified.
 Complete forms 5020 and accident Investigation form and maintain these records.
 Conduct complete investigations of workplace incidents with the intent of determining
corrective actions that would prevent similar types of incidents from reoccurring
 Document the investigation results and maintain these records.
 Implement corrective actions to prevent reoccurrence
 Ensure that Vehicle Accident Report Form Gen. 88 is completed for all vehicle accidents
Employees
 Notify supervisor(s) immediately of any work related injury, illness or accident regardless of
severity
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 Complete necessary documentation as identified by the supervisor and retain copy(s) and
provide originals to the supervisor
 Report all first-aid injuries to the supervisor
 Cooperate in all incident investigations
Safety Coordinator
 Maintain copies of all accident investigations
 Ensure that Cal/OSHA 300 logs are being kept up to date
 Document investigation results and forward a copy to their Department Manager and
Administration section for follow-up review, action, and filing
 Report the results of the accident investigations at the monthly safety meetings.
6.
HAZARD CORRECTION
All DEPARTMENT/DIVISION staff are to identify, evaluate and resolve unsafe work conditions
as soon as practical and to be actively involved in providing recommendations to ensure a safe
workplace. All unsafe/unhealthy conditions, practices or procedures are to be corrected in a
timely manner based on their severity. Hazards are to be corrected when observed or
discovered. Priority is to be given when an imminent hazard exists that cannot be abated
without endangering employee(s) or property. All workers at risk of exposure to imminent
hazards are to be removed from the area except those necessary to correct the existing
condition. Workers necessary to correct the hazardous condition are to be provided with the
appropriate training and necessary protection. Required personal protection equipment will be
provided if workers are needed to correct the hazardous condition. All corrective actions taken
and the dates of completion for all hazards are to be documented.
The DEPARTMENT/DIVISION IIPP encourages the free flow of information of workplace
hazards from all employees to supervisors and managers without fear of reprisal. This policy
also provides a system for reporting unsafe conditions, assisting employees to document their
concerns and contains helpful guidance for responding to and tracking unsafe conditions.
Department Managers
 Implement the Department IIPP and Unsafe Condition Reporting
 Review and sign off on completed unsafe condition report forms
 Be aware and remain informed of unsafe conditions
 Be actively involved in resolving unsafe conditions as required
 Work with and support supervisors and the Safety Coordinator in their effort to resolve unsafe
conditions
Supervisors
When hazards arise that are beyond the ability of the employee to correct, the Supervisor is to
coordinate a resolution with the appropriate personnel to expedite the solution.
 Identify and assess all unsafe/unhealthy conditions
 Track Safety Concern or Suggestion Report to final resolution by documenting all action and
completion dates
 Ensure that all unsafe/unhealthy work conditions within their authority are eliminated or
controlled
 If unable to mitigate the hazard promptly, isolate the area until authorized personnel is able
to correct the hazard.
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 Notify management of any special circumstances which could impede resolution
Employees
 Identify and communicate unsafe/unhealthy conditions to their supervisor to find resolutions
in a timely manner
 The Safety Concern or Suggestion Report form should be completed and submitted to a
supervisor or manager when necessary.
Safety Coordinator
 Ensure that a copy of completed unsafe condition reports is maintained in the central safety
file
 Provide administrative support and recordkeeping assistance to the supervisor so that
hazards or unsafe conditions could be resolved in a timely manner.
7.
TRAINING AND INSTRUCTION
Safety training is intended to raise safety awareness and educate employees about the safety
aspects of their work environment and/or equipment. Training also reinforces existing safety
policies and motivates participation towards a structured safety and health program. Safety
training is oriented towards recognizing and controlling hazards in an employee’s work
environment. All safety training must be documented and records kept in the department or the
employee’s personnel file.
Safety training is required and is to occur when:

The IIPP is significantly revised

A new or transfer employee is hired or assigned to a new job assignment

An unrecognized hazard or unsafe condition is identified and employees are exposed
to the newly identified hazards

An employee uses new or unfamiliar tools/equipment

A new substance, process, procedure or equipment is introduced to the work area

A product, process or procedure creates a safety hazard

An employee's safety performance continually presents a risk to the employee and/or
co-workers

A workplace condition warrants training

An occupational injury or illness occurs or is reoccurring on a frequent basis
Job specific training is to include but is not limited to:
 General and job-specific safety
 Emergency Response Plan
 Safety Concern or Suggestion Report
 Hazard Communication
 Work practices and procedures
 Proper use, inspection and limitations of all machinery and equipment
 Identification of when personal protective equipment is required and its proper use.
Managers and Supervisors
 Ensure employees in their charge understand and are trained in this IIPP, applicable safe
work practices and procedures, safe use of equipment, tools and materials and required
safety training for their job duties
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 Assess an employee’s work skills and ensure that retraining is provided, if needed.
Employees who continually demonstrate deficient safe work practices are to be retrained. If
appropriate, these employees may be disciplined.
 Ensure that all training and tailgates are documented. All safety training must be
documented and maintained onsite at the employees’ reporting location (i.e. Supervisor’s
office)
 Evaluate employee requests for safety training and provide needed training in a timely
manner.
Employees
Attend and actively participate in all required safety and health training and comply with applicable
safety policies and procedures. Employees are to request safety and health training from their
supervisor when:
 Training for a process or procedure has not been previously given
 A new unrecognized hazard is identified
 A new process, procedure or equipment is introduced to the work area that may potentially
create a hazard
 An employee perceives that additional training is needed to work safely
8. RECORD KEEPING
Maintaining documentation is a crucial element for being able to demonstrate the implementation
of the IIPP. In addition, the information gathered from investigations, inspections, and corrective
actions are vital for identifying problems whose resolution will result in improving the effectiveness
of the IIPP.
The DEPARTMENT/DIVISION is responsible for maintaining a log, summary and supplemental
record of all recordable occupational injuries and illnesses (OSHA 300 or equivalent) for the
DEPARTMENT/DIVISION. All requests for injury information should be forwarded to the Safety
Coordinator.
Managers
 Review safety and training documentation and provide comments and suggestions for
improvements.
 Provide the same supervisory function for their direct subordinates as described in the
Supervisor’s section below.
Supervisors
Obtain, complete and maintain documentation on the items listed below: (Copies are to be
forwarded to their Manager).
 Accident/Injury/Near Miss Investigations
 Disciplinary Actions as it relates to safety and health
 Injury or Illness (work-related) requiring medical treatment (Form 66, 5020, 83,
Cal/OSHA Form 300)
 Inspections (shop, equipment, vehicles)
 Tailgate subjects and employee participation
 Vehicle Incidents
 All training records
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Safety Coordinator
Ensure the Administration section maintains the following records (for a minimum of three years):
 Safety Committee Meeting Minutes
 Semi-annual inspections
 Unsafe conditions and work practices identified
 Action(s) taken to correct the unsafe conditions and work practice
 Accident Investigations
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Appendix A
DEPARTMENT - CODE OF SAFE PRACTICES FOR OFFICE AREAS
1. Each staff member is to observe safe working methods and procedures and assist in acquainting
new staff members with our concerns for safety.
2. Office equipment is to be arranged in such a manner as to provide safe working conditions.
3. Unskilled persons are not permitted to operate or tamper with office machines.
4. Un-jamming and servicing photocopy machines present electrical hazards and exposure to hot
surfaces. Only specifically trained staff members are to open or service the copy machines.
5. Office machines and their cords are to be guarded as needed and required by law or regulation.
Telephone cords and electrical cords to computers or other equipment are to be maintained in such
a manner as will present no tripping hazard. Frayed or badly worn cords are to be replaced. Cords
should not be allowed to come in contact with heat producing equipment, such as portable heaters.
When unplugging any appliance, pull by the plug, not the wire.
6. Machines are never to be cleaned or adjusted while in operation. If appropriate, the electrical
power shall be disconnected.
7. Equipment or machines in need of repair are to be removed from service immediately and not
returned to use until properly repaired.
8. Installation, repair, or maintenance of any office equipment is to be done only by qualified persons.
9. Hand paper cutters are to have the blade in the down position at all times when not in use. If the
blade guard is missing, take the cutter out of service.
10. Filing cabinets and bookcases shall be sufficiently secured to the floor or wall to prevent tipping
during earthquakes.
11. When not in actual physical use, all desk and file drawers are to be kept closed so as to avoid
tripping hazards or limiting safe use of aisles. Not more than one file drawer in one file cabinet shall
be opened at one time. Opening additional drawers could over-balance the file, causing all of the
drawers to roll out on the staff member. Staff members are not to stand on or in an open file drawer
as a means of reaching higher objects.
12. Ladders or step stools of adequate design to support the staff member's weight and the material to
be obtained are provided and readily available as a means of reaching high files and upper locker
and/or storeroom shelves. No staff member is to stand on a box, table, desk, swivel or folding chair
for any such purpose. Reaching above shoulder height should be avoided.
13.
All hazards, such as sharp file cabinet edges, splintered wood furniture or any other conditions
likely to do bodily harm, damage clothing, or constitute a fire hazard shall be reported to your
supervisor.
14.
Wastebaskets are provided as receptacles for waste paper only.
15.
Aisles are to be kept clear of obstructions at all times.
16
16.
Personal protective equipment such as goggles and hearing protection will be provided as
necessary based on a Hazard Evaluation from the Safety Coordinator. It is to be worn when and
where prescribed.
17.
Machine guards or other safety devices on machinery shall not be removed or by-passed in any
way.
18.
Hazardous chemicals are to be used only for their intended purpose and in the manner prescribed
on their labels. Protective equipment required by labels is to be worn. Employees are not
permitted to bring hazardous chemicals or products from home to use at work (i.e., bug spray, nail
polish remover, cleaning products).
19.
Report all unsafe conditions, work-related accidents, near misses, injuries or illnesses to your
supervisor.
20.
In the event of fire, immediately notify all co-workers according to the procedures outlined in the
Building Emergency Plan.
21.
Upon hearing the fire alarm, stop work immediately and proceed to the nearest clear exit. Gather
in the safe refuge area so attendance may be taken and to account for all employees.
22.
Means of egress are to be kept clear, well lighted and unlocked during working hours.
23.
Staff members are not to store excessive combustibles (paper) in work areas.
24.
Aisles and hallways are to be kept clear at all times.
25.
Workplaces are to be kept free of debris, floor storage and trip hazards (i.e. electrical cords in
walkways).
26.
Staff members must exercise caution when moving about the office. Do not read while walking
from one place to another. When walking around corners, slow down and look around corner. Do
not carry pencils/pens with sharp points protruding form your pockets.
27.
Cups are to be covered if taken from one area to another. Spills create slip hazards and must be
cleaned up immediately.
28.
Do not lean excessively back in a chair. The chair can tip over.
29.
Lift with your legs, not your back. For heavy objects use a handcart or get help.
30.
Always turn off electricity to equipment before performing maintenance or replenishing supplies.
31.
Pull paper cutter blade to closed position and latch when you are through using the paper cutter.
32.
When not in use, retract carton cutter blades.
33.
When clearing jams in copying machines, do not rest your arms inside the machine where a burn
hazard may exist.
17
Safety Concern or Suggestion
Report
If the safety concern creates a hazard to employees and needs immediate attention, please notify your supervisor or
contact the Occupational Safety and Health Division at (213) 473-3392 or (213) 473-3373. All personal information
contained on this form is confidential.
Name:
Phone Number:
(OPTIONAL)
(OPTIONAL)
Site or Facility Address:
Date:
Include a brief description of the safety concern or safety suggestion, include the location in which it can be
investigated.
Has this safety concern been brought to the attention of your supervisor?
Yes
Date:
No
Was Administrative Services Division notified regarding safety related
repairs?
Yes
Date:
No
Pease indicate your desire:
No NOT reveal my name to my supervisor
My name MAY be revealed to my supervisor
Do you want the Safety Staff to contact you?
Yes
No
Phone No:
18
Hazard Removal/Abatement Form
You may identify hazardous conditions. The next step is to eliminate these hazards. Use this form to
record actions taken to correct hazards.
Date:
Area Inspected:
Identified Hazard or concern:
The steps to be taken to remove the hazard:
Deadline for removing hazard (date):
Hazard has been successfully removed/abated on (date):
Notes:
Supervisor’s Signature:
Date:
19
WORKSHEET FOR REPORTING
FATALITIES/SERIOUS INJURY OR ILLNESS TO Cal/OSHA
1. Name/Job Title of the Person Calling:
2. Time and date of call:
3. Phone number called:
4. Name of OSHA operator or representative:
5. Case/ Report #:
6. Injured Person(s) Name, Gender, Age, Address and Telephone Number:
7. Nature of the Injury (or Injuries):
8. Time/Date of the Accident:
9. Location where the Injured Person(s) was(were) moved to :
10. Site Address of the Accident or Event:
11. Contact Person:
12. Identify any law enforcement agencies, emergency medical response agencies, etc, that are
administering assistance:
13. Describe the accident and whether the accident scene has been altered:
20
Accident Investigation Forms
City of Los Angeles
Accident investigation forms/statements consist of the Employee’s Report of Injury, Accident Witness Statement, and
Supervisor’s Accident Investigation. The supervisor should provide these to the appropriate individuals for completion
after any accident or near miss incident that could have resulted in an accident.
IMPORTANT - Obtaining signed statements as soon as possible following an accident insures that the employer has an
accurate account of how the injury occurred, helps correct hazards to prevent the accident from recurring, and assures
the employee’s claim is documented.
After I have these forms completed, what do I do with them?
1. For all accidents or near miss incidents (regardless of the outcome): the supervisor should complete any
corrective actions identified during the investigation to prevent recurrence of the incident and document this on the
Supervisor’s Accident Investigation form. The supervisor should also keep copies of all the forms for future reference.
2. For all accidents that result in the employee filing a workers’ compensation claim: in addition to step 1 above,
 submit a copy of these forms to the Personnel Department Safety Division
 submit a copy of these forms to the Workers’ Compensation Division along with the Employer’s Report of
Occupational Injury or Illness (Form 5020) and the Workers’ Compensation Claim Form (DWC 1) to the
Personnel Department Workers’ Compensation Division. Form 5020 and DWC 1 can be obtained on the
City’s intranet at:
http://cityweb.ci.la.ca.us/repository/forms/urldisplay.cfm?id=70
http://cityweb.ci.la.ca.us/repository/forms/urldisplay.cfm?id=486
Safety Division
Attn: Safety Engineer
700 E. Temple St, Room 235
Los Angeles, CA 90012
Mail Stop 391
Workers’ Compensation Division
700 E. Temple Street, Room 210
Los Angeles, CA 90012
Mail Stop 391
Fax: 213-473-3333
Email: per.wcdiv@lacity.org
3. For accidents that result in a fatality or a serious injury (i.e. loss of a member of the body/amputation, in-patient
hospitalization in excess of 24 hours for other than observation, or a serious degree of permanent disfigurement like
crushing or severe burns): in addition to steps 1 and 2 above, the supervisor must notify the nearest Cal-OSHA
District office within 8 hours. For a list of the Cal-OSHA District offices phone numbers and detailed instructions for
reporting serious injuries, please go to the links provided below:
http://www.dir.ca.gov/asp/DoshZipSearch.html
http://per.lacity.org/safety/Safety%20Bulletin%20OSHA%20reporting_1.pdf
http://per.ci.la.ca.us/Safety/Worksheet%20for%20Reporting%20Fatalities-Serious%20Injury-Illness%20to%20CalOSHA.pdf
What if my injured employee is physically unable to fill out the Employee’s Report of Injury?
Use common sense and good judgment. If the injury is severe - remember, your employee’s health and care are first and
foremost. If possible, have the form filled out at a later, more appropriate time when the employee is physically able to
document the accident.
What if my employee refuses to fill out or sign an Employee’s Report of Injury?
Of course, you cannot make an employee fill out the document. You can however stress the importance of getting their
account of the accident to help prevent the injury from happening again. Also, still obtain the supervisor's report as well
as any witness statements.
21
Employee's Report of Injury Form
(To complete by the employee)
Employee's name: _________________________________________________Male___ Female___
Date of birth: ____/____/____
Home telephone # ( ____ ) _________________________
Home address: ____________________________________________________________________
City: ________________________________________ State: ________ Zip Code: ______________
Present classification: _______________________________________________________________
Location of accident:________________________________________________________________
Date of accident: ____________________________ Time of accident: _______________________
Describe fully how accident occurred: (including events that occurred immediately before the
accident):
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Describe bodily injury sustained (be specific about body part(s) affected): ______________________
________________________________________________________________________________
Recommendation on how to prevent this accident from recurring: ____________________________
________________________________________________________________________________
Name of supervisor: ________________________________________ Phone#_________________
Name(s) of witness(es): _____________________________________ Phone#_________________
When did you report the accident to your supervisor? ______________________________________
Who did you report the injury to?______________________________________________________
Do you require medical attention? Yes:_______ No:_______ Maybe:__________
Name of your treating physician: _________________________ Phone#_____________
Signature of employee: ________________________________ Date:________________
22
Accident Witness Statement
(To be completed by Accident Witness)
Injured employee's name: ___________________________________________________________
Name of witness: _______________________________________ Phone # ___________________
Job title of witness: _________________________________________________________________
Home address of witness: ___________________________________________________________
City: ________________________________________ State: __________ Zip Code: ____________
Location of accident: _______________________________________________________________
Date of accident: ___________________________________ Time of accident: _________________
Describe fully how accident occurred: (including events that occurred immediately before the
accident):
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Describe bodily injury sustained (be specific about body part(s) affected): ______________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Recommendation on how to prevent this accident from recurring: ____________________________
________________________________________________________________________________
________________________________________________________________________________
Name of Witnesses Supervisor: ________________________________ Phone #_______________
Signature of Witness: _________________________________________ Date: ________________
23
Supervisor's Accident Investigation
(To be completed by the employee's supervisor or other responsible
administrative official)
Location where accident occurred
Employer's Premises: Yes
Job site:
Who was injured?
Yes
No
Date of accident or illness
No
Employee
Time of accident
a.m.
p.m.
Non-Employee
Job title or occupation
Name of dept. normally assigned
What property/equipment was damaged?
How long has employee worked at job
where injury or illness occurred?
Property/equipment owned by:
What was employee doing when injury/illness occurred? What machine or tool was being used? What type of operation?
How did injury/illness occur? List all objects and substances involved.
Part of body affected/injured?
Any prior physical conditions? If so, what?
Yes
No
Nature and extent of injury/illness and property damaged (be specific)
PLEASE INDICATE ALL OF THE FOLLOWING WHICH CONTRIBUTED TO THE INJURY OR ILLNESS
____ Improper instruction
____ Failure to lockout
____ Unsafe arrangement or process
____ Lack of training or skill
____ Unsafe position
____ Poor ventilation
____ Operating without authority
____ Improper dress
____ Improper guarding
____ Horseplay
____ Improper protective equipment
____ Improper maintenance
____ Physical or mental impairment
____ Unsafe equipment
____ Inoperative safety device
____ Failure to secure
____ Poor housekeeping
____ Other ______________
Supervisor's corrective action to ensure this type of accident does not recur: ______________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Was employee trained in the appropriate use of Personal Protective Equipment/Proper safety procedures?
Yes ___ No ____
Was employee cautioned for failure to use Personal Protective Equipment/Proper safety procedures?
Yes ___ No ____
Did employee promptly report the injury/illness?
Yes ___ No ____
Is there modified duty available?
Yes ___ No ____
Supervisor’s name
Supervisor’s Signature
Phone #
Date
24
SAFETY INSPECTION
CHECKLISTS
City of Los Angeles
DEPARTMENT NAME
SAFETY INSPECTION CHECKLISTS
TABLE OF CONTENTS
Number Subject
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
Forward
General Work Environment
Hazard Communication Program
Personal Protective Equipment
Electrical Safety
Hazardous Chemical Exposure
Confined Space Operations
Fire Safety
Lockout and Tagout Procedures
Medical Services and First Aid
Scaffold Safety
Industrial Noise
Hand and Power Tools and Equipment
Construction Site Safety
Portable Ladder Safety
Transporting Employees and Materials
Machine Guarding Safety
Compressors and Compressed Gas
Cylinders
Motor Vehicle Service and Repair
Operations
Welding and Hotwork Operations
Spray Painting Operations
Hoists and Auxiliary Equipment
Forklifts and Industrial Trucks
2
Page
No.
1
3
5
6
7
9
10
11
13
14
15
16
17
19
20
21
22
23
24
26
27
28
29
FORWARD
SELF-INSPECTION. The most widely accepted way to identify hazards in the workplace is to
conduct safety and health self-inspections. You can only be certain that actual situations exist in the
workplace if you check them from time to time.
Begin a program of self-inspection in your workplace. Self-inspection is necessary if you are to know
where probable hazards exist and whether they are under control.
This document contains twenty-two safety inspection checklists designed to help you evaluate
your work areas. They will give you some indication of where you should begin action to make
your workplace safer and more healthful for your employees.
These checklists are not all inclusive. You may wish to add to them or delete portions that do not
apply to your workplace. Consider carefully each item as you come to it and then make your
decision. Do not spend time with items that have no application to your workplace. Make sure
you check each item on the list and leave nothing to memory or chance. Write down what you see
(or do not see) and what you think should be done about it. YOU MUST COMPLY WITH THE
CALIFORNIA OCCUPATIONAL SAFETY AND HEALTH LAW (CAL-OSHA STANDARDS) FOR
MANY OF THE TOPICS COVERED IN THESE CHECKLISTS.
When you have completed the checklists, you will have enough information to decide if problems
exist. Once you have identified hazards, you can begin corrective actions and control procedures.
SCOPE. The scope of self-inspections should cover the following areas:

Processing, Receiving, Shipping and Storage. Equipment, job planning, layout, heights,
floor loads, materials handling and storage methods.

Building and Grounds.
driveways and aisles.

Housekeeping Program. Waste disposal, tools, objects, materials, leakage and spillage,
cleaning methods, schedules, work areas, remote areas and storage areas.

Electrical. Equipment, switches, breakers, fuses, switch boxes, junctions, special fixtures,
circuits, insulation, extension cords, tools, motors, grounding, compliance with codes.

Lighting. Type, intensity, controls, conditions, diffusion, location, glare and shadow control.

Heating and Ventilation. Type, effectiveness, temperature, humidity, controls, natural and
artificial ventilation and exhausting.

Machinery. Points of operation, flywheels, gears, shafts, pulleys, key ways, belts, couplings,
sprockets, chains frames, controls, lighting for tools and equipment, brakes, exhausting,
feeding, oiling, adjusting, maintenance, lockout, grounding, work space, location and
purchasing standards.
Floors, walls, ceilings, exits, stairs, walkways, ramps, platforms,
3
FORWARD CONTINUED

Personnel. Training, experience, methods of checking machines before use, clothing,
personnel protective equipment, use of guards, tool storage, work practices, method of
cleaning, oiling or adjusting machinery.

Hand and Power Tools.
Purchasing standards, inspection, storage, repair, types,
maintenance, grounding, use and handling.

Chemicals. Storage, handling, transportation, spills, disposal, amounts used, toxicity or other
harmful effects, warning signs, supervision, material safety data sheets, supervision, training,
personal protective equipment and clothing.

Fire Prevention.
Extinguishers, alarms, sprinklers, smoking rules, exits, personnel
assignments, separation of flammable materials and dangerous operations, explosive proof
fixtures in hazardous locations and waste disposal.

Maintenance. Regularity, effectiveness, training of personnel, materials and equipment used,
records maintained, method of locking out machinery and general methods.

Personal Protective Equipment. Type, size, maintenance, repair, storage, assignment of
responsibility, purchasing methods, standards observed, training in care and use, rules of use
and method of assignment.
4
SAFETY INSPECTION CHECKLIST NO. 1
GENERAL WORK ENVIRONMENT
Department/Division: _____________________________________________ Date Of Inspection: ____________
Location: _____________________________________ Inspector: _____________________________________
Criteria
Yes
Are work areas properly illuminated?
Is the ventilation system appropriate for the work performed?
Are restrooms and washrooms kept clean and sanitary?
Is potable water provided for drinking and washing?
Are outlets for water not suitable for drinking clearly identified?
Where heat stress is a problem, do all fixed work areas have air conditioning?
Is the work area clean and orderly?
Are floors kept clean and dry or have you taken appropriate measures to make floors slip resistant?
Are floors free from protruding nails, splinters, holes, etc.?
Are permanent aisles and passageways clearly marked?
Are aisles and passageways kept clear?
Are pits and floor openings covered or guarded?
Is combustible trash removed from the worksite daily?
Are spilled materials or liquids cleaned up immediately?
Is there safe clearance in aisles where motorized or mechanical handling equipment travel?
FLOOR AND WALL OPENINGS, STAIRS AND STAIRWAYS
Are floor openings guarded by covers or guardrails on all sides?
Do skylights have screens or fixed railings that would prevent someone on the roof from falling through?
Are open pits and trap doors guarded?
Are grates or similar type covers over floor openings such as floor drains, designed so that foot traffic or
rolling equipment are not affected by grate spacing?
Are open-sided floors, platforms and runways having a drop of more than 4 feet guarded by a standard
railing or toe board?
Are standard stair rails or handrails on all stairways having four or more risers?
Are all stairways at least 22 inches wide?
Do stairs have at least a 6-½ foot overhead clearance?
Are step risers on stairs uniform from top to bottom?
Are steps on stairs and stairways designed or provided with a slip-resistant surface?
Are stairway handrails located between 30 and 34 inches above the leading edge of stair treads?
Are stairway handrails capable of withstanding a load of 200 pounds, applied in any direction?
ELEVATED SURFACES
Is the vertical distance between stairway landings limited to 12 feet or less?
Are stairways adequately illuminated?
Are signs posted showing the elevated surface load capacity?
5
No
N/A
Do elevated work areas have a permanent means of access and egress?
Are materials on elevated surfaces piled, stacked or racked in a manner to prevent tipping, falling,
collapsing, rolling or spreading?
EXITS AND EXIT DOORS
Are all exits marked with an exit sign and illuminated by a reliable light source?
Are exit routes clearly marked?
Are doors, passageways or stairways that are neither exits nor access to exits, appropriately marked
“NOT AN EXIT” or “STOREROOM” etc.?
Are all exits kept free of obstructions?
Are there sufficient exits to permit prompt escape in case of emergency?
Do exit doors open in the direction of exit travel?
Are doors that swing in both directions provided with viewing panels in each door?
Are exits and exit routes equipped with emergency lighting?
ADDITIONAL REMARKS:
6
SAFETY INSPECTION CHECKLIST NO. 2
HAZARD COMMUNICATION PROGRAM
Department/Division: _____________________________________________ Date Of Inspection: ____________
Location: _____________________________________ Inspector: _____________________________________
Criteria
Do you have an inventory of all hazardous substances used in your workplace?
Is there a written hazard communication program that covers Material Safety Data Sheets (MSDS),
labeling and employee training?
Is there a MSDS readily available for each hazardous substance used?
Is there an employee training program for hazardous substances?
Does the employee training program include:

An explanation of what a MSDS is and how to use and obtain it?

The physical and health hazards of substances in the work area, and specific protective measures
to be used?

Employee access to the employer’s written hazard communication program and where hazardous
substances are present in their work areas?
An explanation of the “Right to Know” standards?


Details of the hazard communication program, including how to use the labeling system and
MSDS?
ADDITIONAL REMARKS:
7
Yes
No
N/A
SAFETY INSPECTION CHECKLIST NO. 3
PERSONAL PROTECTIVE EQUIPMENT
Department/Division: _____________________________________________ Date Of Inspection: ____________
Location: _____________________________________ Inspector: _____________________________________
Criteria
Is personal protective equipment (PPE) provided, used and maintained when required?
Are protective goggles, face shields or glasses used where there is a danger of flying
particles or corrosive materials splash?
Are protective gloves, aprons, shields or other means provided and used to prevent cuts
and corrosive liquid or chemical splash injuries?
Are hard hats provided and worn where there is a danger of falling objects?
Are employees trained in the selection, use and maintenance of PPE and protective
clothing?
Is appropriate foot protection provided and used where there is a risk of foot injuries from
hot, corrosive substances or falling objects or crushing or penetrating actions?
Is hearing protection provided and use when noise levels exceed HIOSH noise
standards?
RESPIRATORY PROTECTION
Is respiratory protection provided and used when required?
Do you have a written respiratory protection program?
Do you have written procedures for the selection, use and maintenance of respirators?
Are employees instructed and trained in the limitations, proper use and care of respirators
used?
Are respirators cleaned, disinfected and inspected after every use?
Is the proper respirator used for the hazard present?
Are respirators stored in a convenient, clean and sanitary location?
Are emergency use respirators inspected monthly and are records of monthly inspections
kept?
Are users of negative pressure respirators fit tested?
Are respirator users given periodic physical examinations?
ADDITIONAL REMARKS:
8
Yes
No
N/A
SAFETY INSPECTION CHECKLIST NO. 4
ELECTRICAL SAFETY
Department/Division: _____________________________________________ Date Of Inspection: ____________
Location: _____________________________________ Inspector: _____________________________________
Criteria
Do you specify compliance with CAL-OSHA Standards for all electrical work contacted out to private
entities?
Are employees instructed to make preliminary inspections and tests to determine what conditions exist
before starting electrical work?
When electrical equipment or lines are serviced, maintained or adjusted, are necessary switches
opened, locked-out when possible and tagged?
Are all portable electrical tools and equipment either grounded or double insulated?
Are all electrical appliances such as refrigerators, vacuum cleaners, vending machines, etc. grounded?
Do extension cords have a grounding conductor?
Are ground-fault circuit interrupters used at locations where construction, demolition, modification,
alteration or excavation operations are being performed?
At the junction with permanent wiring, do suitable disconnecting switches or plug connectors protect all
temporary circuits?
Do you repair or replace wiring and cords with frayed or deteriorated insulation promptly?
Are flexible cords and cables free of splices?
Are clamps or other securing means provided on flexible cords or cables at plugs, receptacles, tools,
equipment, etc., and is the cord jacket securely held in place?
In wet or damp locations, are electrical tools and equipment appropriate for use?
Do you establish the location of electrical power lines and cables (overhead, underground, other side of
walls, etc.) before digging, drilling, demolition or other similar work begins.
Do you prohibit the use of metal ladders in areas where the ladder or person using the ladder could
come in contact with energized parts of equipment or circuit conductors?
Are all disconnecting switches and circuit breakers labeled to indicate their use or the equipment they
serve?
Do you disconnect electrical circuits before replacing fuses?
Do all wiring systems include provisions for grounding metal parts of electrical raceways, equipment and
enclosures?
Are all energized parts of electrical circuits and equipment guarded by approved cabinets or enclosures
against accidental contact?
Do you maintain sufficient access and working space around all electrical equipment to permit ready
and safe operation and maintenance?
Are all unused openings (including conduit knockouts) in electrical enclosures and fittings closed with
appropriate covers, plugs or plates?
Are electrical enclosures such as switches, receptacles, junction boxes, etc., provided with tight fitting
covers or plates?
Are employees who regularly work on or around energized electrical equipment or lines instructed in
cardiopulmonary resuscitation (CPR)?
Are employees prohibited from working alone on energized lines or equipment?
9
Yes
No
N/A
ADDITIONAL REMARKS
10
SAFETY INSPECTION CHECKLIST NO. 5
HAZARDOUS CHEMICAL EXPOSURE
Department/Division: _____________________________________________ Date Of Inspection: ____________
Location: _____________________________________ Inspector: _____________________________________
Criteria
Yes
Are employees trained in safe handling practices of hazardous chemicals such as acids, bases,
caustics, epoxies, phenols, etc.?
Is employee exposure to chemicals within acceptable levels?
Are eye wash fountains and showers provided where hazardous chemicals are handled?
Are employees required to use personal protective equipment when handling chemicals (gloves,
aprons, boots, eye and face protection, respirators, etc.)?
Are chemical piping systems marked as to their content?
Are all containers such as vats, storage tanks, etc., labeled as to their contents (e.g., “CAUSTICS”)?
Have written standard operating procedures been published for handling chemicals and are they being
followed?
Where needed for emergency use, are respirators stored in a sanitary, clean and convenient location?
Do you maintain medical and biological monitoring systems for hazardous chemical processes?
Do employees complain about dizziness, headache, nausea, irritation or others discomfort factors when
they use chemicals?
Is there a dermatitis problem (e.g., employees complain about dryness, irritation or sensitization of the
skin)?
Have control measures been instituted for hazardous materials such as exhaust ventilation systems,
handling procedures and personal protective equipment?
Is vacuuming used, rather than blowing or sweeping dusts whenever possible?
Have written standard operating procedures been established and are they followed for chemical spill
cleanup?
ADDITIONAL REMARKS:
11
No
N/A
SAFETY INSPECTION CHECKLIST NO. 6
CONFINED SPACE OPERATIONS
Department/Division: _____________________________________________ Date Of Inspection: ____________
Location: _____________________________________ Inspector: _____________________________________
Criteria
Is a Confined Space Entry Permit, signed by the entry supervisor, provided prior to any permit required
confined space?
Are confined spaces thoroughly emptied of any corrosive or hazardous substances (acids or caustics)
before entry?
Are all lines to a confined space containing inert, toxic, flammable or corrosive materials, shut off and
blanked, disconnected or separated before entry?
Is it required that impellers, agitators or other moving equipment inside confined spaces be locked-out
and tagged before entry?
Is exhaust ventilation required before confined space entry?
Are gas tests performed for oxygen deficiency, toxic substances and explosive concentrations before
confined space entry?
Is there adequate illumination for confined space work?
Is the atmosphere inside the confined space periodically tested or continuously monitored during the
conduct of work?
Is there an assigned safety standby employee outside of the confined space, when required, whose sole
responsibility is to watch the work in progress, sound an alarm and render assistance if necessary?
Is the standby employee trained and equipped to handle an emergency?
Is the standby employee prohibited from entering the confined space in an emergency unless relieved
by a qualified safety standby and equipped with lifelines and respiratory equipment?
Is communication provided between the standby employee and confined space entrants, as well as
emergency rescue personnel?
Is self-rescue equipment provided?
Is safety equipment and clothing provided when required?
Is approved respiratory equipment required if the atmosphere inside the confined space cannot is
hazardous?
Before gas welding or cutting is started in a confined space, are hoses checked for leaks, compressed
gas cylinders forbidden in the confined space, torches lighted outside the confined space, and is the
confined area tested for toxic and combustible gases?
Is exhaust ventilation required when welding or hazardous materials are used in a confined space?
ADDITIONAL REMARKS:
12
Yes
No
N/A
SAFETY INSPECTION CHECKLIST NO. 7
FIRE SAFETY
Department/Division: _____________________________________________ Date Of Inspection: ____________
Location: _____________________________________ Inspector: _____________________________________
Criteria
Yes
FIRE PROTECTION
If you have an alarm system, is it tested annually?
Are fire door and shutter fusible links in place?
Are fire doors operating properly and unobstructed?
Are automatic sprinkler system water control valves and water pressure checked periodically?
Is the maintenance of automatic sprinkler systems assigned to competent persons or to a sprinkler
contractor?
Is proper clearance maintained below sprinkler heads?
Are fire extinguishers provided in adequate number and type?
Are fire extinguishers serviceable and mounted in readily accessible locations?
Are fire extinguishers inspected monthly and noted on the inspection tag?
Are employees instructed in the use of fire extinguishers?
Are required fire extinguishers mounted within 75 feet of any outside areas containing flammable liquids,
and within 10 feet of any inside storage areas?
Is access to fire extinguishers free of obstruction?
Are all fire extinguishers serviced and maintained at intervals not exceeding one year?
Are all fire extinguishers fully charged and in designated locations?
Are fire extinguishers selected and provided for the class(es) of fires expected based on materials
stored in the area?
o
Class A: Ordinary combustible material fires.
o
Class B: Flammable liquid, gas or grease fires.
o
Class C: Energized – electrical equipment fires.
FLAMMABLE AND COMBUSTIBLE MATERIALS
Are combustible scrap, debris and waste materials (oily rags, etc.) stored in covered noncombustible
containers and promptly removed from the worksite?
Is proper storage practiced to minimize the risk of fire, including spontaneous combustion?
Are approved containers and tanks used for the storage and handling of flammable and combustible
liquids?
Are all flammable liquids kept in closed containers when not in use (e.g., parts cleaning tanks, pans,
etc.)?
Are bulk drums of flammable liquids grounded and bonded to containers during dispensing?
Do storage rooms for flammable and combustible liquids have explosion proof lights and mechanical or
gravity ventilation?
13
No
N/A
Are firm separators placed between containers of combustibles or flammables, when stacked one upon
another, to insure support and stability?
Are fuel gas cylinders and oxygen cylinders separated by 20 feet or fire resistant barriers 5 feet in height
during storage?
Is liquefied petroleum gas stored, handled and used in accordance with safe practices and standards?
Are liquefied petroleum gas storage tanks guard to prevent damage from vehicles?
Are “NO SMOKING” signs posted on liquefied petroleum gas storage tanks?
Are “NO SMOKING” signs posted in areas where flammable or combustible materials are used or
stored?
Are “NO SMOKING” rules enforced in areas where flammable or combustible materials are used or
stored?
Are all solvents and flammable wastes kept in fire resistant, covered containers and promptly removed
from the worksite?
Are approved containers used for storage and dispensing flammable or combustible liquids?
ADDITIONAL REMARKS:
14
SAFETY INSPECTION CHECKLIST NO. 8
LOCKOUT AND TAGOUT PROCEDURES
Department/Division: _____________________________________________ Date Of Inspection: ____________
Location: _____________________________________ Inspector: _____________________________________
Criteria
Yes
Is all equipment capable of movement deenergized or disengaged, and blocked or locked-out during
cleaning, servicing, adjusting or setting up operations?
Do you prohibit locking out of control circuits in lieu of locking out main power disconnects?
Does the lockout procedure require that stored energy (mechanical, hydraulic, air, etc.) be released or
blocked before equipment is locked out for repairs?
Are appropriate employees provided with individually keyed personal safety locks?
Are employees required to keep personal control of their key(s) while they have safety locks in use?
Is the employee exposed to the hazard the only one who can place or remove the safety lock?
Do employees check the safety of the lockout by attempting to start up the machine after making sure
no one else is exposed?
Are employees instructed to always push the control circuit stop button prior to reenergizing the main
power switch?
Is there a means provided to identify all employees who are working on locked-out equipment by their
locks or accompanying tags?
In the event that the equipment cannot be shut down and locked-out, has a safe tag-out procedure been
established and rigidly followed?
ADDITIONAL REMARKS:
15
No
N/A
SAFETY INSPECTION CHECKLIST NO. 9
MEDICAL SERVICES AND FIRST AID
Department/Division: _____________________________________________ Date Of Inspection: ____________
Location: _____________________________________ Inspector: _____________________________________
Criteria
Yes
Is there a hospital, clinic or infirmary nearby?
Are emergency phone numbers conspicuously posted?
Where required, are employees trained and certified in first aid?
Are City approved first aid kits accessible in each work area and are they periodically inspected for
required components?
Are first aid kits replenished as supplies are used?
Are employees trained in Cardiopulmonary Resuscitation (CPR) as necessary?
Do employees know what to do in case of emergency?
Are emergency showers and eyewashes available where corrosive liquids or materials are handled?
Are employee medical records and records of employee exposure to hazardous substances up-to-date
and maintained for the period of time required by law?
ADDITIONAL REMARKS:
16
No
N/A
SAFETY INSPECTION CHECKLIST NO. 10
SCAFFOLD SAFETY
Department/Division: _____________________________________________ Date Of Inspection: ____________
Location: _____________________________________ Inspector: _____________________________________
Criteria
Yes
Is a competent person in charge of scaffold erection?
Is the scaffold on stable footing?
Is the scaffold level and plumb?
Are all scaffold legs braced with braces properly attached?
Is the scaffold guarded on all open sides with toe boards installed?
Has proper access to the scaffold been provided?
Has overhead protection or screening been provided as necessary?
Has the scaffold been tied to the structure every 30 feet in length and 26 feet in height?
Is scaffold free of makeshift devices or ladders to increase height?
Are freestanding towers guyed or tied every 26 feet in height?
Are working levels fully planked between guardrails?
Have personnel been instructed in scaffold safety?
ADDITIONAL REMARKS:
17
No
N/A
SAFETY INSPECTION CHECKLIST NO. 11
INDUSTRIAL NOISE
Department/Division: _____________________________________________ Date Of Inspection: ____________
Location: _____________________________________ Inspector: _____________________________________
Criteria
Yes
Are there areas in the workplace where continuous noise levels exceed 85 decibels (dBA)?
Is there an ongoing preventive health program to educate employees in safe noise levels, exposures,
the effects of noise on their health and the use of personal protective equipment?
Have work areas where noise levels make voice communication between employees difficult been
identified and posted?
Are noise levels measured using a sound level meter, noise dosimeter or octave band analyzer and are
records kept?
Have engineering controls been used to reduce excessive noise levels?
Where engineering controls are determined to be unfeasible, have administrative controls (i.e., worker
rotation) been instituted to minimize individual employee exposure to noise?
Is approved hearing protective equipment (noise attenuating devices) available to all employees working
in noisy areas?
Have you isolated noisy equipment from the rest of your operation?
If you use ear protectors, are employees properly fitted and instructed in their proper use?
Are employees in high noise areas given periodic audiometric testing to ensure that you have an
effective hearing protection program?
ADDITIONAL REMARKS:
18
No
N/A
SAFETY INSPECTION CHECKLIST NO. 12
HAND AND POWER TOOLS AND EQUIPMENT
Department/Division: _____________________________________________ Date Of Inspection: ____________
Location: _____________________________________ Inspector: _____________________________________
Criteria
Yes
HAND TOOLS AND EQUIPMENT
Are tools and equipment (City and personal) in good condition?
Are chisels, punches or other mushroomed head tools repaired or replaced?
Are broken handles on hammers and axes replaced promptly?
Are worn or bent wrenches repaired or replaced?
Do files have handles?
Is eye and face protection worn while using hand tools that might produce flying materials or breakage?
Have employees been trained to use hand tools properly?
Are jacks checked to assure they are in good operating condition and marked with the jack capacity?
PORTABLE POWER TOOLS AND EQUIPMENT
Are grinders, saws and similar equipment used with appropriate safety guards?
Are portable circular saws equipped with guards above and below the base shoe?
Are rotating or moving parts guarded to prevent physical contact?
Are all cord-connected, electrically operated tools and equipment grounded or double insulated?
Are guards in placed over belts, pulleys, chains and sprockets on equipment such as concrete mixers,
air compressors, etc.?
Are portable fans provided with full guards having openings of ½ inch or less?
Are Ground Fault Circuit Interrupters (GFCI) used with portable electrical power tools?
Is compressed air used for cleaning reduced to a nozzle pressure of 30 psi or less?
Are pneumatic and hydraulic hoses on power-operated tools inspected regularly for serviceability?
Is portable hoisting equipment posted with capacity and latest load test information?
Do chain saws have anti-kickback devices?
ABRASIVE WHEEL GRINDERS
Is the work rest adjusted to within 1/8 inch on the wheel?
Is the tongue guard adjusted to within ¼ inch of the wheel?
Do side guards cover the spindle, nut and flange and 75% of the wheel diameter?
Are bench and pedestal grinders permanently mounted?
Are goggles or face shields always worn while grinding?
Is the maximum RPM rating of each abrasive wheel compatible with the RPM rating of the grinder
motor?
Does each grinder have an individual on and off control?
Are dust collectors or powered exhausts provided?
POWER ACTUATED TOOLS
Are employees who operate power-actuated tools trained in their use and do they carry a valid
operators card?
Is each power-actuated tool stored in its own locked container when not being used?
19
No
N/A
Is a sign at least 7” x 10” with bold face type reading “POWER ACTUATED TOOL IN USE”
conspicuously placed to warn others that the tool is being used?
Are power-actuated tools left unloaded until they are ready to be used?
Are power actuated tools inspected for obstructions or defects each day before use?
Do power actuated tool operators have and use appropriate personal protective equipment (head, eye,
hearing, etc.)?
ADDITIONAL REMARKS:
20
SAFETY INSPECTION CHECKLIST NO. 13
CONSTRUCTION SITE SAFETY
Department/Division: _____________________________________________ Date Of Inspection: ____________
Location: _____________________________________ Inspector: _____________________________________
Criteria
Yes
MECHANICAL EQUIPMENT
Are rollover protection structures (ROPS) provided for agricultural equipment and scrapers, front-end
loaders, bulldozers, wheel-type industrial tractors, crawler tractors and motor graders?
Are backup alarms provided?
Are crane operators licensed and do they have proper medical clearances?
Has the crane pre-operation checklist been completed by the operator prior to operations?
Has crane been load tested periodically?
EXCAVATING AND TRENCHING
Are walls and faces or trenches 5 feet or more in depth and entered by workers exposed to cave-in,
guarded by shoring or sloping of ground?
Is excavated material placed two or more feet from the edge of the excavation?
Is heavy equipment kept a safe distance from the edge of the excavation to prevent cave-in?
Is the ladder provided for exiting the trench located within 25 feet of those working in the trench?
Are signs, barricades and flagmen used to warn motorist when excavating or trenching work is done in
roadways?
Do workers in the vicinity of roadways use safety vests for visibility?
Are tools such as shovels, picks, hammers, etc. kept away from the edge of trenches to prevent injury to
those working in the trench?
Are excavations being carried out following the Construction Standards set forth in the Hawaii
Administrative Rules (Chapter 132.2, Excavations)?
ADDITIONAL REMARKS:
21
No
N/A
SAFETY INSPECTION CHECKLIST NO. 14
PORTABLE LADDER SAFETY
Department/Division: _____________________________________________ Date Of Inspection: ____________
Location: _____________________________________ Inspector: _____________________________________
Criteria
Yes
Are all ladders maintained in good condition?
Is each ladder equipped with non-slip safety feet?
Are ladder rungs and steps free of grease and oil?
Are ladders prohibited from being placed on unstable bases (such as boxes, barrels, truck beds, etc.) to
gain added height?
Do employees face the ladder and use both hands when climbing and descending the ladder?
Are unserviceable ladders discarded?
Do ladders extend at least 3 feet above the landing?
Are rungs of ladders uniformly spaced at 12 inches?
Do employees stand on the top step of ladders?
Are portable metal ladders marked with signs reading, “CAUTION – DO NOT USE AROUND
ELECTRICAL EQUIPMENT?”
ADDITIONAL REMARKS:
22
No
N/A
SAFETY INSPECTION CHECKLIST NO. 15
TRANSPORTING EMPLOYEES AND MATERIALS
Department/Division: _____________________________________________ Date Of Inspection: ____________
Location: _____________________________________ Inspector: _____________________________________
Criteria
Yes
Do employees who operate City vehicles have valid driver licenses (Type 3, 4 or Commercial Drivers
License – CDL)?
When more than 15 employees are transported in a van, bus or truck, is the operator’s CDL appropriate
for the vehicle operated?
Is each van, bus or truck used to transport employees equipped with an adequate number of seats?
When employees are transported by truck, are provisions made to prevent their falling from the vehicle?
Are vehicles used to transport employees equipped with handrails, steps or similar devices so that
employees can enter and leave the vehicle safely?
Are vehicles equipped with lamps, brakes, horns, mirrors, windshields and turn signals in good
operating condition?
Are transport vehicles equipped with at least two reflective type flares?
Is a fully charged and serviceable fire extinguisher, at least 4 B:C rating maintained in each transport
vehicle?
When cutting tools or tools with sharp edges are carried in passenger compartments of employee
transport vehicles, are they place in closed boxes or containers secured in place?
Are employees prohibited from riding on top of any load that can shift, topple or otherwise become
unstable?
Is there a driver improvement program for commercial drivers and are records kept of training received
by each driver?
ADDITIONAL REMARKS:
23
No
N/A
SAFETY INSPECTION CHECKLIST NO. 16
MACHINE GUARDING SAFETY
Department/Division: _____________________________________________ Date Of Inspection: ____________
Location: _____________________________________ Inspector: _____________________________________
Criteria
Yes
Is there a training program to instruct employees on safe methods of machine operation?
Is there a regular safety inspection program for equipment?
Do you clean and properly maintain machinery and equipment?
Is adequate space provided around and between equipment to permit set-up, servicing, material
handling and waste removal?
Is equipment anchored to prevent tipping or movement?
Is there a power shutoff switch within reach of the operator’s position for each machine?
Are all emergency stop buttons colored red?
Can power to each machine be locked-out for maintenance, repair or security purposes?
Are non-current carrying metal parts of electrically operated machines bonded and grounded?
Are foot operated switches guarded to prevent accidental activation by personnel or falling objects?
Are pulleys and belts that are within 7 feet of the floor or working level properly guarded?
Are moving chains and gears properly guarded?
Are machines guarded to protect the operator and other employees in the area from ingoing nip points,
rotating parts, flying chips and sparks and other hazards created at the point of operation?
Are provisions made to prevent machines from automatically starting when power is restored after a
power failure or shutdown?
Are fan blades protected with a guard having openings no larger than ½”, when operating within 7 feet
of the floor?
Are saws used for ripping, equipped with anti-kick back devices and spreaders?
Are radial arm saws arranged so that the cutting head will gently return to the back of the table when
released?
Is eye protection used when operating machines?
ADDITIONAL REMARKS:
24
No
N/A
SAFETY INSPECTION CHECKLIST NO. 17
COMPRESSORS AND COMPRESSED GAS CYLINDERS
Department/Division: _____________________________________________ Date Of Inspection: ____________
Location: _____________________________________ Inspector: _____________________________________
Criteria
Yes
Are compressors equipped with pressure relief valves and pressure gauges?
Are air filters installed on the compressor intakes?
Are safety devices on compressed air systems check frequently?
Are signs posted to warn of the automatic starting feature of the compressor?
Is the belt drive system guarded to provide protection for the front, back, top and sides?
Is compressed air used for cleaning reduced to less than 30 psi at the nozzle?
When using compressed air for cleaning, is eye and face protection provided and worn?
Are locking devices used at couplings of high-pressure hose lines?
Is every air receiver equipped with a pressure gauge with one or more automatic, spring-loaded safety
valve(s)?
Is every air receiver provided with a drainpipe and valve at the lowest point for removal of accumulated
oil and water?:
Is the air receiver’s inlet and piping system kept free of accumulated oil and carbon materials?
COMPRESSED GAS CYLINDERS
Are cylinders equipped with a valve protection device?
Are cylinders clearly marked to identify the gas they contain?
Are cylinders stored in an area protected from high heat sources?
Are cylinders stored or transported in a manner to prevent them from tipping, falling or rolling?
Are valve protectors always placed on cylinders when they are not in use or connected for use?
Are valves closed before a cylinder is moved, when the cylinder is empty and at the completion of each
job?
Are cylinders checked periodically for corrosion, general distortion, cracks or any other defect that may
render them unserviceable or hazardous?
ADDITIONAL REMARKS:
25
No
N/A
SAFETY INSPECTION CHECKLIST NO. 18
MOTOR VEHICLE SERVICE AND REPAIR OPERATIONS
Department/Division: _____________________________________________ Date Of Inspection: ____________
Location: _____________________________________ Inspector: _____________________________________
Criteria
Yes
FUELING
Is fueling prohibited while the vehicle engine is running?
Do fueling operations minimize the likelihood of spillage?
Are fuel tank caps replaced and secure before starting engine?
When fuel spills, is the spillage washed away completely, evaporated or other measures taken to control
vapors before starting the engine?
During fueling, is there always metal contact between the container and the fuel tank?
Are fueling hoses designed to handle the specific type of fuel dispensed?
Is it prohibited to handle or transfer fuel in unapproved containers?
Are open lights, flames or sparking, or arcing equipment prohibited near fueling or fuel transfer
operations?
Is smoking prohibited near fueling operations?
Where fueling or transfer of fuel is done through gravity flow, are the nozzles self closing?
SERVICING AND MAINTAINING EQUIPMENT
Are vehicles chocked or blocked to prevent unexpected movement?
Are floors free of grease, gas or oil and is absorbent available to cleanup spills immediately?
Is eye protection and protective apparel used when steam cleaning?
Are traffic lanes and parking spaces marked on the garage floor and does staff ensure compliance with
these markings?
Is gasoline used as a solvent to clean tools, parts or hands?
Is the rated load permanently marked on jacks and stands?
Is a block placed between the jack cap and load?
Are jacks and stands serviceable?
Do jacks and stands have positive stops to prevent over travel?
Is jewelry worn when servicing vehicles?
Is compressed air used for cleaning regulated to less than 30 psi at the nozzle and do employees wear
eye protection?
TIRE OPERATIONS
Is there a published “Safe Operating Procedure” for tire repairs and is it enforced?
Does each tire inflation hose have a clip-on chuck and in-line valve and gauge?
Does the tire inflation control valve automatically shut off the airflow when the valve is released?
Is a tire restraining device such as a cage, rack or other effective means used while inflating tires
mounted on split rims, or rims using retainer rings?
Are employees strictly forbidden from taking a position directly over or in front of a tire while it is being
inflated?
BATTERY CHARGING
Is eye protection, acid resistant gloves and apron provided and used when measuring specific gravity or
26
No
N/A
servicing of batteries?
Are quick drenching shower and eye wash facilities immediately available and serviceable?
Are spark producing devices and smoking prohibited in the area?
ADDITIONAL REMARKS:
27
SAFETY INSPECTION CHECKLIST NO. 19
WELDING AND HOTWORK OPERATIONS
Department/Division: _____________________________________________ Date Of Inspection: ____________
Location: _____________________________________ Inspector: _____________________________________
Criteria
Yes
Are only authorized and trained personnel permitted to use welding, cutting or brazing equipment?
Are compressed gas cylinders examined regularly for obvious defects such as rusting or leakage?
Are only approved torches, regulators, pressure reducing valves, acetylene generators and manifolds
used?
Are gas cylinders kept away from heat sources?
Are gas cylinders stored away from stairs, elevators and exits?
Are empty cylinders marked and are the valves closed and protected by valve caps?
Are cylinders, valves, couplings, regulators, hoses and apparatus kept free of oil and grease?
Unless secured on special trucks, are regulators removed and valve caps installed before moving
cylinders?
Do cylinders have keys, handles or non-adjustable wrenches on stem valves when in service?
Are cylinders stored and shipped valve-end up with valve caps on?
Is red used to identify the acetylene hose, green the oxygen hose and black for inert gas and air hose?
Is a fire extinguisher available for immediate use?
Do you periodically check the grounding of the machine frame and safety ground connections of
portable machines?
Is the welder prohibited from coiling the electrode cable around his body?
Are wet machines dried and tested before use?
Are work and electrode lead cables inspected for wear and damage prior to use, and replaced as
necessary?
When fire hazards cannot be removed, are shields used to confine heat, sparks and slag?
Are firewatchers assigned when welding or cutting is done in locations where a serious fire may occur?
When floors are wet, are personnel protected from possible electrical shock?
When welding or cutting is done on walls, are precautions taken to protect combustibles on the other
side?
Are employees who are exposed to the hazards of welding, cutting or brazing protected with personal
protective equipment?
Is a check made for adequate ventilation when welding or cutting is done?
When working in confined spaces, are tests for toxic and combustible gases taken prior to welding,
cutting or brazing?
ADDITIONAL REMARKS:
28
No
N/A
SAFETY INSPECTION CHECKLIST NO. 20
SPRAY PAINTING OPERATIONS
Department/Division: _____________________________________________ Date Of Inspection: ____________
Location: _____________________________________ Inspector: _____________________________________
Criteria
Yes
Do you have adequate ventilation before spray operations begin?
Is the spray area kept clean of combustible residue?
Is mechanical exhaust ventilation provided when spraying operations are conducted in enclosed areas?
Is the spray area at least 20 feet from flames, sparks, electrical motors and other ignition sources?
Is approved respiratory equipment provided and used during spraying operations?
Are fire sprinkler heads kept free of spray residue?
Are “NO SMOKING” signs posted in spray areas, paint rooms, paint booths and paint storage areas?
Are spray booths constructed of noncombustible material?
Are electric motors for exhaust fans placed outside spray booths?
Are electrical motors, lights, etc., approved for use in hazardous locations?
ADDITIONAL REMARKS:
52
No
N/A
SAFETY INSPECTION CHECKLIST NO. 21
HOISTS AND AUXILIARY EQUIPMENT
Department/Division: _____________________________________________ Date Of Inspection: ____________
Location: _____________________________________ Inspector: _____________________________________
Criteria
Yes
Is each overhead hoist equipped with a limit device to stop the hook travel at its highest and lowest point
of safe travel?
Will each hoist automatically stop and hold any load up to 125% of its rated load, if the actuating force is
removed?
Is the rated load of each hoist legibly marked and visible to the operator?
Are stops provided at the safe limits of travel for trolley hoists?
Are close fitting guards installed to assure hoist ropes will be maintained in sheave grooves?
Are nip points or contact points between hoist ropes and sheaves located within 7 feet of the surface
guarded?
Is the use of unserviceable chains or rope slings prohibited?
Is the operator prohibited from carrying loads over people?
Are only employees who have been trained in the proper use of hoists allowed to operate them?
ADDITIONAL REMARKS:
30
No
N/A
SAFETY INSPECTION CHECKLIST NO. 22
FORKLIFTS AND INDUSTRIAL TRUCKS
Department/Division: _____________________________________________ Date Of Inspection: ____________
Location: _____________________________________ Inspector: _____________________________________
Criteria
Yes
Are only trained personnel allowed to operate industrial trucks?
Is overhead protection provided on rider lift trucks?
Does each industrial truck have a warning device that can be clearly heard above the normal noise in the
operating area?
Are lift truck operating rules posted and enforced?
Are brakes on industrial trucks capable of bringing the vehicle to a complete and safe stop when fully
loaded?
Will the industrial truck’s parking brake prevent the vehicle from moving when unattended?
Are forklift loads lowered while the truck is traveling?
Are industrial trucks operating in areas where flammable gases or vapors, or combustible dust or
ignitable fibers may be present in the atmosphere, approved for such locations?
Are motorized hand and hand/rider trucks designed so when the brakes are applied, power to the drive
motor shut off when the operator releases his grip on the device that controls the travel?
Are industrial trucks with internal combustion engines, operating in buildings or enclosed areas, carefully
checked to ensure such operations do not cause harmful concentrations of dangerous gases or fumes?
ADDITIONAL REMARKS:
31
No
N/A