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Safety Inspection Report Template: Submitted By: Jheremae D. Deypalubos

This safety inspection report template contains sections to document potential hazards, their rating, and notes for various areas of a workplace including entrance ways, office areas, emergency and fire safety, first aid, personal protective equipment, and general concerns. The inspector documents their findings in each section including hazards requiring immediate attention, attention as soon as possible, or attention. The completed report is reviewed and signed by worker and management representatives.

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Mika
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266 views4 pages

Safety Inspection Report Template: Submitted By: Jheremae D. Deypalubos

This safety inspection report template contains sections to document potential hazards, their rating, and notes for various areas of a workplace including entrance ways, office areas, emergency and fire safety, first aid, personal protective equipment, and general concerns. The inspector documents their findings in each section including hazards requiring immediate attention, attention as soon as possible, or attention. The completed report is reviewed and signed by worker and management representatives.

Uploaded by

Mika
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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SAFETY INSPECTION REPORT

TEMPLATE

Submitted by:
Jheremae D. Deypalubos
SAFETY INSPECTION REPORT
Date of Inspection: Persons Participating in Inspection:
Company:

Class “A” Hazard: Serious hazard requiring immediate attention (Stop Work)
Class “B” Hazard: Hazard requiring attention as soon as possible.
Class “C” Hazard: Hazard requiring attention
ENTRANCE WAYS
RATE
POSSIBLE HAZARDS HAZARDS NOTES/COMMENTS:
Is the front entrance well lit?    
Are all door closure devices    
working properly?    
Are all doors free of sharp objects?    
Are all threshold plates on all doors secure? No
protruding screws?    
Are solid glass door marked to alert customers?    
Any other Concerns?(if yes, indicate in comment
column)    
 
OFFICE AREAS
RATE
POSSIBLE HAZARDS HAZARDS NOTES/COMMENTS:
Housekeeping acceptable?    
Aisle ways, Emergency Exits clear?    
Have all fire extinguishers been inspected within the last
year?    
Is the tag initialed and dated?    
Is emergency lighting inspected?    
Is the employee lunchroom area acceptable?
   
Electrical – are all cords and wires in good condition and
out of the way?    
Are supplies and other material stored in or on shelves or
file cabinets properly to avoid overloading and/or
tipping?    
Housekeeping acceptable?    
Aisle ways, Emergency Exits clear?    
Are exterior Exits clear?    
Any other Concerns? (if yes, indicate in comment
column)    

EMERGENCY AND FIRE


RATE
POSSIBLE HAZARDS HAZARDS NOTES/COMMENTS:
Is there an emergency phone numbers list next to the
phone(s)?    
Are Emergency numbers current and easy to read?    
Are all Emergency exits clearly identified?    
Are all exit doors completely free of debris and/or other
obstructions?    
Have all fire extinguishers been inspected within the last
year?    
Is the tag initialed and dated?    
Is there a criteria list that identifies what is being
checked on all fire extinguishers each month?    
Are all electrical cords and wires in good condition,
secured and out of the way?    
Are all employees aware of their responsibilities with
respect to our    
Fire Emergency Plan, as they relate to customers and
visitors?    
Are all employees trained in the company’s Emergency
Evacuation Procedure?    
Any other Concerns? (If yes, indicate in comment
column)    
 
FIRST AID SAFETY
RATE
POSSIBLE HAZARDS HAZARDS NOTES/COMMENTS:
Is there an “In Case of Injury” Poster (Form 82) located
at the First Aid Station?    
Is there the appropriate First Aid Kit available at the
facility for the number of employees employed?
   
Is the First Aid Kit inspected each month?    
Is documentation of inspection available?    
Is there someone with a valid First Aid Certificate of
Qualification at the facility?    
Is the certificate of the First Aid Attendant current? (Not
more than 3 years from date of certification)    
Is the Joint Health and Safety Committee (JHSC) or the
Health and Safety Representative reviewing the First Aid
reports?    
Any other Concerns? (If yes, indicate in comment
column)    
 
PERSONAL PROTECTIVE EQUIPMENT
POSSIBLE HAZARDS RATE NOTES/COMMENTS:
HAZARDS
Is there an adequate inventory of PPE available in the
workplace?    
Are employees using required personal protective
equipment?    
Any other Concerns? (If yes, indicate in comment
column)    
 
GENERAL
RATE
POSSIBLE HAZARDS HAZARDS NOTES/COMMENTS:
Is there a Health and Safety Policy posted at the facility?
   
Are the names and location of the Joint Health and
Safety Committee members or the name of the Health
and Safety Representative posted?    
Are the most recent Joint Health and Safety Committee
meeting minutes posted?    
Are the Ontario Occupational Health and Safety Act and
the Industrial Establishments Regulations posted where
they are easily accessible to all employees?
   
Any other Concerns? (If yes, indicate in comment
column)    
Workers Contacted and their concerns?    
Supervisors Contacted and Concerns?    

Signature of Inspector: Reviewed by worker Reviewed by Reviewed by


Co-Chair Management Co-Chair Management
(Signature and Date): (Signature and Date): (Signature and Date)

Notes:

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