Quarterly Facility Safety Inspection Test Form

Date:

Facility

Person conducting inspection

Employee #

GENERAL SAFETY

Safety programs available for employee review

--Recommended Action

Safety posters are displayed as required

--Recommended Action

Hazard assessment process is being done as required

--Recommended Action

WORK AREA

Worksites are kept clean and orderly

--Recommended Action

Combustible waste is removed from premises daily

--Recommended Action

Spills and leaks are cleaned up immediately

--Recommended Action

Floor surfaces are in good repair

--Recommended Action

Heavy items stored low, light items stored high

--Recommended Action

Ladders are available and in good condition

--Recommended Action

Shelves and cabinets secured to prevent toppling

--Recommended Action

Hanging items, appliance equipment secure in place

--Recommended Action

Lighting is adequate for job condition

--Recommended Action

Trip hazards are clearly marked (steps and stairs)

--Recommended Action

Plumbing fixtures are working properly, no leaks

--Recommended Action

Toilets and washing facilities kept sanitary

--Recommended Action

Furniture is kept in good repair

--Recommended Action

Windows & glass doors are in good order, no cracks

--Recommended Action

Doors between apparatus room and other areas closed

--Recommended Action

Eating and drinking are done in appropriate areas

--Recommended Action

EQUIPMENT/TOOLS

Power equipment is in good working condition

--Recommended Action

Tools are in good condition & replaced when damaged

--Recommended Action

Adequate clearance is maintained near machinery

--Recommended Action

Employee protective equipment is available and used

--Recommended Action

Protective machine guards are in place

--Recommended Action

Only authorized personnel permitted in work area

--Recommended Action

Emergency eye wash/showers operate properly

--Recommended Action

Lift truck policies are enforced

--Recommended Action

EXITING

--Recommended Action

Hallways, corridors & exits are clear of obstacles

--Recommended Action

All exit door hardware is operable

--Recommended Action

Emergency lighting is in working order

--Recommended Action

FIRE PROTECTION

Portable fire extinguishers are available & serviced

--Recommended Action

No smoking policies are enforced

--Recommended Action

Test smoke detectors; replace battery Jan & July

--Recommended Action

Combustible storage kept away from ignition sources

--Recommended Action

Storage is kept below 24" of ceiling, no sprinklers

--Recommended Action

Storage is kept 18" below sprinkler heads

--Recommended Action

Sprinkler heads not obstructed or damaged

--Recommended Action

Sprinkler heads and wrench are available

--Recommended Action

Sprinkler system valves in “OPEN” position

--Recommended Action

30" clearance of combustibles from heating equipment

--Recommended Action

Sprinkler system 5 yr. service completed/tagged

--Recommended Action

Hoods above cooking equip are in good order/clean

--Recommended Action

Address numbering is visible from the street

--Recommended Action

Fire lanes are kept clear

--Recommended Action

Emergency fuel shutoffs are clearly marked & tested

--Recommended Action

Welding/flame cutting policies are enforced

--Recommended Action

ELECTRICAL

Electrical fixtures and wiring are in good repair

--Recommended Action

Only approved extension cords are in use

--Recommended Action

30" clearance in front of electrical panel

--Recommended Action

Ground fault interrupters near water sources

--Recommended Action

HAZARDOUS MATERIALS

Oily rags are kept in approved metal container

--Recommended Action

Storage of flammables are in approved locations

--Recommended Action

Hazardous materials are stored safely

--Recommended Action

All containers are properly labeled

--Recommended Action

Biohazards are properly disposed of

--Recommended Action

WORKPLACE SAFETY AND SECURITY

All exterior lighting works properly and provides adequate illumination

--Recommended Action

All facility bedroom and bathroom doors have the ability to be locked from the inside

--Recommended Action

Internal emergency alarm system works properly

--Recommended Action

AED is present and operable per AED checklist

--Recommended Action

First Aid Kit is stocked appropriately

--Recommended Action

MISCELLANEOUS

H.V.A.C. equipment in good working order

--Recommended Action

Pits and floor openings are covered/protected

--Recommended Action

Overhead doors are in good working order

--Recommended Action

Air compressor unit in good working order/inspected

--Recommended Action

Compressed gas cylinders are secured

--Recommended Action

Exhaust removal systems work properly

--Recommended Action

Gates and fence components securely standing

--Recommended Action

Other

DATE AND SIGN

Name of Inspector

Date

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