Quarterly Facility Safety Inspection Test Form Date: Facility Person conducting inspection Employee # GENERAL SAFETY Safety programs available for employee reviewSelect Option Complete N/A Action Needed --Recommended Action Safety posters are displayed as requiredSelect Option Complete N/A Action Needed --Recommended Action Hazard assessment process is being done as requiredSelect Option Complete N/A Action Needed --Recommended Action WORK AREA Worksites are kept clean and orderlySelect Option Complete N/A Action Needed --Recommended Action Combustible waste is removed from premises dailySelect Option Complete N/A Action Needed --Recommended Action Spills and leaks are cleaned up immediatelySelect Option Complete N/A Action Needed --Recommended Action Floor surfaces are in good repairSelect Option Complete N/A Action Needed --Recommended Action Heavy items stored low, light items stored highSelect Option Complete N/A Action Needed --Recommended Action Ladders are available and in good conditionSelect Option Complete N/A Action Needed --Recommended Action Shelves and cabinets secured to prevent topplingSelect Option Complete N/A Action Needed --Recommended Action Hanging items, appliance equipment secure in placeSelect Option Complete N/A Action Needed --Recommended Action Lighting is adequate for job conditionSelect Option Complete N/A Action Needed --Recommended Action Trip hazards are clearly marked (steps and stairs)Select Option Complete N/A Action Needed --Recommended Action Plumbing fixtures are working properly, no leaksSelect Option Complete N/A Action Needed --Recommended Action Toilets and washing facilities kept sanitarySelect Option Complete N/A Action Needed --Recommended Action Furniture is kept in good repairSelect Option Complete N/A Action Needed --Recommended Action Windows & glass doors are in good order, no cracksSelect Option Complete N/A Action Needed --Recommended Action Doors between apparatus room and other areas closedSelect Option Complete N/A Action Needed --Recommended Action Eating and drinking are done in appropriate areasSelect Option Complete N/A Action Needed --Recommended Action EQUIPMENT/TOOLS Power equipment is in good working conditionSelect Option Complete N/A Action Needed --Recommended Action Tools are in good condition & replaced when damagedSelect Option Complete N/A Action Needed --Recommended Action Adequate clearance is maintained near machinerySelect Option Complete N/A Action Needed --Recommended Action Employee protective equipment is available and usedSelect Option Complete N/A Action Needed --Recommended Action Protective machine guards are in placeSelect Option Complete N/A Action Needed --Recommended Action Only authorized personnel permitted in work areaSelect Option Complete N/A Action Needed --Recommended Action Emergency eye wash/showers operate properlySelect Option Complete N/A Action Needed --Recommended Action Lift truck policies are enforcedSelect Option Complete N/A Action Needed --Recommended Action EXITING --Recommended Action Hallways, corridors & exits are clear of obstaclesSelect Option Complete N/A Action Needed --Recommended Action All exit door hardware is operableSelect Option Complete N/A Action Needed --Recommended Action Emergency lighting is in working orderSelect Option Complete N/A Action Needed --Recommended Action FIRE PROTECTION Portable fire extinguishers are available & servicedSelect Option Complete N/A Action Needed --Recommended Action No smoking policies are enforcedSelect Option Complete N/A Action Needed --Recommended Action Test smoke detectors; replace battery Jan & JulySelect Option Complete N/A Action Needed --Recommended Action Combustible storage kept away from ignition sourcesSelect Option Complete N/A Action Needed --Recommended Action Storage is kept below 24" of ceiling, no sprinklersSelect Option Complete N/A Action Needed --Recommended Action Storage is kept 18" below sprinkler headsSelect Option Complete N/A Action Needed --Recommended Action Sprinkler heads not obstructed or damagedSelect Option Complete N/A Action Needed --Recommended Action Sprinkler heads and wrench are availableSelect Option Complete N/A Action Needed --Recommended Action Sprinkler system valves in “OPEN” positionSelect Option Complete N/A Action Needed --Recommended Action 30" clearance of combustibles from heating equipmentSelect Option Complete N/A Action Needed --Recommended Action Sprinkler system 5 yr. service completed/taggedSelect Option Complete N/A Action Needed --Recommended Action Hoods above cooking equip are in good order/cleanSelect Option Complete N/A Action Needed --Recommended Action Address numbering is visible from the streetSelect Option Complete N/A Action Needed --Recommended Action Fire lanes are kept clearSelect Option Complete N/A Action Needed --Recommended Action Emergency fuel shutoffs are clearly marked & testedSelect Option Complete N/A Action Needed --Recommended Action Welding/flame cutting policies are enforcedSelect Option Complete N/A Action Needed --Recommended Action ELECTRICAL Electrical fixtures and wiring are in good repairSelect Option Complete N/A Action Needed --Recommended Action Only approved extension cords are in useSelect Option Complete N/A Action Needed --Recommended Action 30" clearance in front of electrical panelSelect Option Complete N/A Action Needed --Recommended Action Ground fault interrupters near water sourcesSelect Option Complete N/A Select Option --Recommended Action HAZARDOUS MATERIALS Oily rags are kept in approved metal containerSelect Option Complete N/A Action Needed --Recommended Action Storage of flammables are in approved locationsSelect Option Complete N/A Action Needed --Recommended Action Hazardous materials are stored safelySelect Option Complete N/A Action Needed --Recommended Action All containers are properly labeledSelect Option Complete N/A Action Needed --Recommended Action Biohazards are properly disposed ofSelect Option Complete N/A Action Needed --Recommended Action WORKPLACE SAFETY AND SECURITY All exterior lighting works properly and provides adequate illuminationSelect Option Complete N/A Action Needed --Recommended Action All facility bedroom and bathroom doors have the ability to be locked from the insideSelect Option Complete N/A Action Needed --Recommended Action Internal emergency alarm system works properlySelect Option Complete N/A Action Needed --Recommended Action AED is present and operable per AED checklistSelect Option Complete N/A Action Needed --Recommended Action First Aid Kit is stocked appropriatelySelect Option Complete N/A Action Needed --Recommended Action MISCELLANEOUS H.V.A.C. equipment in good working orderSelect Option Complete N/A Action Needed --Recommended Action Pits and floor openings are covered/protectedSelect Option Complete N/A Action Needed --Recommended Action Overhead doors are in good working orderSelect Option Complete N/A Action Needed --Recommended Action Air compressor unit in good working order/inspectedSelect Option Complete N/A Action Needed --Recommended Action Compressed gas cylinders are securedSelect Option Complete N/A Action Needed --Recommended Action Exhaust removal systems work properlySelect Option Complete N/A Action Needed --Recommended Action Gates and fence components securely standingSelect Option Complete N/A Action Needed --Recommended Action - Other DATE AND SIGN Name of Inspector Date There was a problem saving your submission. 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