Inspection Form

INSPECTION FORM DATE: COMPANY NAME: COMPANY ADDRESS: COMPANY CONTACT: BUSINESS TYPE: TOTAL EMPLOYEES: _____________ COMPANY SAFETY COMMITTEE: TOTAL SAFETY COMMITTEE MEMBERS TOTAL EMPLOYER MEMBERS TOTAL EMPLOYEE MEMBERS SAFETY COMMITTEE CHAIRPERSON DATE SELECTED DATE OF LAST SAFETY MEETING YES TELEPHONE # PPO: YES NO NO _____________ _____________ _____________ _____________ _____________ _____________ DOES THE COMPANY HAVE A MASTER LIST OF SAFETY COMMITTEE MEMBERS? YES NO IF YES, DOES THIS MASTER LIST CONSIST OF MEMBER NAMES AND THEIR DEPARTMENTS? YES NO IS THIS LIST POSTED WHERE ALL EMPLOYEES HAVE ACCESS? YES NO ARE SAFETY MEETING MINUTES KEPT? YES NO IF YES, DO THESE MEETING MINUTES LIST THE ATTENDEES? YES NO ARE ALL MEMBERS OF THE SAFETY COMMITTEE PAID FOR ALL TIME SPENT ON COMMITTEE ACTIVITIES? YES NO American LegalNet, Inc. www.FormsWorkFlow.com DO SAFETY COMMITTEE MEETINGS INCLUDE: ACCIDENT INVESTIGATIONS YES SAFETY INSPECTIONS YES SAFETY TRAINING PROGRAMS YES HAZARD IDENTIFICATION AND/OR WORKPLACE EXPOSURE PROGRAMS YES FOLLOW-UP PROCEDURES FOR OPEN SAFETY ITEMS YES A WRITTEN AGENDA YES A RECORD OF ALL SUGGESTIONS AND RECOMMENDATIONS YES FREQUENCY OF SAFETY MEETINGS DURATION OF SAFETY MEETINGS ARE RESPONSIBILITIES ASSIGNED TO CORRECT SAFETY ISSUES? NO NO NO NO NO NO NO _______________ _______________ YES NO HAVE ALL SAFETY COMMITTEE MEMBERS BEEN TRAINED IN THEIR RIGHTS AND RESPONSIBILITIES AS COMMITTEE MEMBERS? YES NO IF YES, HOW? _______________________________________ American LegalNet, Inc. www.FormsWorkFlow.com