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Poultry Survey
Guidance for Filling Out Poultry Survey
What the survey is designed to be:
- Snapshot of Health and Safety conditions in facility.
- Opportunity for subjective opinion of S&H professional on problems leading to recordable events.
- Tool to pinpoint which areas are problematical and allow for the selection of appropriate remedies.
- A reminder of various items which can cause particular types of injuries and illnesses.
What the survey is not designed to be:
- A compliance checklist, i.e. not every negative checkmark equals a citation.
- A rigorous statistical tool. Not every line item is equivalent in weight to the others.
- A time consuming number crunching exercise.
How the survey is intended to be conducted:
Opening conference. Request copies of the OSHA 200 log and 101s for three years. Scan OSHA 200 log quickly.
Conduct walk around inspection. Make notes on relative frequency of potential problems. Interview management
and labor representatives about the safety and health program, cursorily review the safety programs referenced
in the survey (LO/TO, Confined Space, PSM, PPE, etc.), categorize the injuries and illnesses according to the
survey headings (Slips; Falls; Bruises; Ergo Backs; Ergo Wrists/Elbows; Ergo Shoulders). Fill out the Survey
form utilizing professional judgment on the relative weight of the findings' impact on recordable safety and
health events. Submit the form and the supporting records to DCP.
Name of Facility and Location______________________________
Name of Surveyor_______________________________________
Record Keeping
Is there a designated person or point of contact (POC) for maintaining the OSHA 200 log?
[ ]Yes [ ]No
Is there an established procedure for reporting injuries to the POC?
[ ]Yes [ ] No
Are injuries and illnesses recorded promptly?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Does the POC understand the difference between lost workday and non-lost workday events?
[ ]Yes [ ]No
Does the POC understand the difference between recordable and non-recordable events?
[ ]Yes [ ]No
Are employees and supervisors trained to report recordable events?
[ ]Yes [ ]No
Is there an onsite or first medical provider?
[ ]Onsite [ ]Offsite
Is the information flow between the first medical provider adequate for recording purpose?
[ ]Yes [ ]No
Based upon a review of the OSHA 200 and OSHA 101 data, what is the Lost and Restricted Workday Incidence for
all injury and illness events for each year in a three year period? 1995___, 1996___, 1997___, Average___.
What are the top three events leading to lost workday events?
1.
2.
3.
What is the average employment and hours for the three years? 1995___, 1996___, 1997___, Average___
What is the employee turnover rate for 1997? (100) (#employees hired during 97/avg.# employee in 97)=%
Turnover=____________________
Does OSHA have copies of OSHA 200 logs for each of the three years?
[ ]Yes [ ]No
Slips, Trips and Falls to Same Level
Based upon the review of the OSHA 200 and OSHA 101 data, what number and percent of Lost and Restricted Workday
Events over a three year period result from exposure to this type of hazard. Number______% of
total=________________________
Are aisles and passageways kept clear?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are aisles and walkways marked as appropriate?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are wet surfaces covered with non-slip materials?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are employees issued or required to wear slip resistant footwear?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are holes in the floor, sidewalk or other walking surface repaired properly, covered or otherwise made
safe?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are grates or similar type covers over floor openings such as floor drains of such design that foot traffic or
rolling equipment will not be affected by the grate spacing?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Is there safe clearance for walking in aisles where motorized or mechanical handling equipment is
operating?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are materials or equipment stored in such a way that sharp projectives will not interfere with the
walkway?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are spilled materials cleaned up immediately?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are changes of direction or elevations readily identifiable?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Is adequate headroom provided for the entire length of any aisle or walkway?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Based upon the above observation and analysis, to what degree is the hazard of slips, trips and falls
controlled in this facility?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Struck By, Struck Against, Caught In
Based upon a review of the OSHA 200 and OSHA 101 data, what number and percent of Lost and Restricted Workday
Events over a three year period result from exposure to this type of hazard.
Struck By: Number____% of total=_______
Struck Against: Number____% of total=_______
Caught In: Number___% of total=_______
What percent of events resulted from cuts?
MACHINE GUARDING
Is there a training program to instruct employees on safe methods of machine operation?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Is there adequate supervision to ensure that employees are following safe machine operating procedures?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Is there a regular program of safety inspection of machinery and equipment?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Is all machinery and equipment kept clean and properly maintained?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Is sufficient clearance provided around and between machines to allow for safe operations, set up and
servicing, material handling and waste removal?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Is equipment and machinery securely placed and anchored, when necessary to prevent tipping or other movement
that could result in personal injury?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Is there a power shut-off switch within reach of the operator's position at each machine?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are foot-operated switches guarded or arranged to prevent accidental actuation by personnel or falling
objects?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are manually operated valves and switches controlling the operation of equipment and machines clearly
identified and readily accessible?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are all emergency stop buttons colored red?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are power tools used with the correct shield, guard, or attachment, recommended by the manufacturer?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are all pulleys and belts that are within 7 feet of the floor or working level properly guarded?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are all moving chains and gears properly guarded?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are all rotating or moving parts of equipment guarded to prevent physical contact?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are guarding methods provided to protect the operator and other employees in the machine area from hazards
created at the point of operation, ingoing nip points, rotating parts, flying chips, and sparks?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are machinery guards secure and so arranged that they do not offer a hazard in their use?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
If special hand tools are used for placing and removing material, do they protect the operator's hands?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are provisions made to prevent machines from automatically starting when power is restored after a power
failure or shutdown?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
If machinery is cleaned with compressed air, is air pressure controlled and personal protective equipment or
other safeguards utilized to protect operators and other workers from eye and body injury?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are fan blades protected with a guard having openings no larger than 1/2 inch (1.2700 centimeters), when
operating within 7 feet of the floor?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are saws or rotating knives used for cutting poultry guarded fully?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Is hoisting equipment available and used for lifting heavy objects, and are hoist ratings and characteristics
appropriate for the task?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are pneumatic and hydraulic hoses on power-operated tools checked regularly for deterioration or damage?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A
Comments:
Is material on elevated surfaces piled, stacked or racked in a manner to prevent it from tipping, falling,
collapsing, rolling or spreading?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
LOCKOUT/TAGOUT PROCEDURES
Is all machinery or equipment capable of movement, required to be de-energized or disengaged and locked-out
during cleaning, servicing, adjusting or setting up operations, whenever required:
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Can electric power to each machine be locked out for maintenance, repair, or security?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Where the power disconnecting means for equipment does not also disconnect the electrical control circuit:
Are the appropriate electrical enclosure identified?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A
Comments:
Is means provided to assure the control circuit can also be disconnected and locked-out?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Is the locking-out of control circuits in lieu of locking-out of manpower disconnects
prohibited?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are all equipment control valve handles provided with a means for locking-out?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Does the lock-out procedure require that stored energy (mechanical, hydraulic, air, etc.) be released or
blocked before equipment is locked-out for repairs?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are appropriate employees provided with individually keyed personal safety locks?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are employees required to keep personal control of their key(s)?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Is it required that only the employee exposed to the hazard, place or remove the safety lock?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are employees instructed to always push the control circuit stop button immediately after checking the safety
of the lock-out?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Is there a means provided to identify any or all employees who are working on locked-out equipment by their
locks or accompanying tags?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are sufficient numbers of accident preventive signs or tags and safety padlocks provided for any reasonably
foreseeable repair emergency?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
When machine operation, configuration or size requires the operator to leave his or her control station to
install tools or perform other operations, and that part of the machine could move if accidentally activated,
is such element required to be separately locked or blocked out?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
In the event that equipment or lines cannot be shut down, locked-out and tagged, is a safe job procedure
established and rigidly followed?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
STORAGE PROCEDURE
Is required headroom provided where necessary?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Based upon the above observations and analysis, to what degree is the hazard of struck by, struck against, and
caught in controlled in this facility?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Falls To Lower Surfaces
Based upon a review of the OSHA-200 and OSHA 101 data, what number and percent of Lost and Restricted Workday
Events over a three year period result from exposure to this type of hazard. Number___ % of total=_____.
ELEVATED SURFACES
Are surfaces elevated more than 48 inches above the floor or ground provided with standard guardrails?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are all elevated surfaces (beneath which people or machinery could be exposed to falling objects) provided with
standard 4-inch toeboards?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Is a permanent means of access and egress provided to elevated storage and work surfaces?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are dock boards or bridge plates used when transferring materials between docks and trucks or rail cars?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
STAIRS AND STAIRWAYS
Are standard stair rails or handrails on all stairways having four or more risers?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are all stairways at least 22 inches wide?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Do stairs have landing platforms not less than 30 inches in the direction of travel and extending 22 inches in
width at every 12 feet or less or vertical rise?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Do stairs angle no more than 50 and no less than 30 degrees?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are stairs of hollow-pan type treads and landings filled to the top edge of the pan with solid material?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are step risers on stairs uniform top to bottom?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are steps on stairs and stairways designed or provided with a surface that renders them slip resistant?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are stairway handrails located between 30 and 34 inches above the leading edge of stair treads?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Do stairway handrails have at least 3 inches of clearance between the handrails and the wall or surface they
are mounted on?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Where doors or gates open directly on a stairway, is a platform provided so the swing of the door does not
reduce the width of the platform to less than 21 inches?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are stairway handrails capable of withstanding a load of 200 pounds, applied within 2 inches of the top edge,
in any downward or outward direction?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Where stairs or stairways exit directly into any area where vehicles may be operated, are adequate barriers and
warnings provided to prevent employees stepping into the path of traffic?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Do stairway landings have a dimension measured in the direction of travel, at least to the width of the
stairway?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Is the vertical between stairway landings limited to 12 feet or less?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
PORTABLE LADDERS
Are all ladders maintained in good condition, joints between steps and side rails tight, all hardware and
fittings securely attached and moveable parts operating freely without binding or undue play?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are employees instructed in proper ladder usage?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Is it prohibited to place ladders on boxes, barrels, or other unstable bases to obtain
additional height?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are employees instructed not to use the top step of ordinary stepladders as step?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Based upon the above observations and analysis, to what degree is the hazard of falls
from elevations controlled in this facility?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Ergonomic Hazards: Repetitive Motion and Lifting
Based upon a review of the OSHA 200 and OSHA 101 data, what number and percent of Lost
and Restricted Workday Events over a three year period result from exposure to this type of hazard. Total
Ergonomic Related Events: Number___ ; Wrist/Forearm/Elbow Illness: Number___% of total=_____;Shoulder/Neck
Illness: Number___% of total=_____;Back Pain, Injury or Illness Number___ % of total=_____
How many employees perform repetitive upper extremity motions every several seconds? Are
the following risk factors are associated with the above jobs.
Extended Reaches?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Overhead Work?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Elbow/forearm Twisting?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Hand/Wrist Bend/Pinch?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Trunk Twisting?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
How many employees perform jobs associated with repetitive manual lifting of weights 25 -
50 lbs?
How many employees perform jobs associated with repetitive manual lifting of weights
greater than 50 lbs?
Does the facility review injury and illness records, incident reports, or employee
complaints to identify jobs with ergonomic hazards?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Does the facility conduct hazard evaluation on jobs where injuries occur?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Does the facility implement the findings of the hazard evaluation in a constructive
manner?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Does the facility have a regularly scheduled sharpening program for positions performing
work with knives?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A
Comments:
Does the facility encourage the early reporting of symptoms of musculoskeletal
disorders?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A
Comments:
Does the facility medical management program review cases of reported musculoskeletal
disorders?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A
Comments:
Is the facility management program under the control of a
[ ]Occupational Nurse, [ ]Occupational Physician, [ ]Industrial Hygienist, [ ]Safety
Professional, [ ]Qualified Staff Person, [ ]Other Comments:
Do employees have easy access to medical care during all shifts at the facility?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Does the facility's restricted activity program require medical clearance for each job
assigned to a restricted person?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A
Comments:
Does the facility provide training on ergonomic hazard recognition to employees exposed
to ergonomic stressors?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A
Comments:
Based upon the above observations and analysis, to what degree is the hazard of
musculoskeletal disorders controlled in this facility?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A
Comments:
Health Hazards
Based upon a review of the OSHA 200 and OSHA 101 data, what number and percent of Lost
and Restricted Workday Events over a three year period result from exposure to health hazards?
Total Ergonomic Related Events: Number___ ; % of total=_____
Chemical (Skin, airways, lung, etc.) Number___ % of total=_____;
Biological (infection, hypersensitivity, etc.): Number___ % of total=_____;
Physical (Noise, Heat Stress) Number___ % of total=_____
Lungs and airways: Number___ % of total=_____.
HAZARDOUS MATERIALS
Are employees trained in the safe handling practices of hazardous chemicals such as
acids, caustics, ammonia etc?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Is employee exposure to chemicals kept within acceptable levels?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are eye wash fountains and safety showers provided in areas where corrosive chemicals are
handled?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are all containers, such as vats, and storage tanks labeled as to their contents and with
appropriate hazard warnings?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A
Comments:
Is personal protective equipment (clothing, gloves, eye protection, and respirators)
provided, used and maintained whenever necessary? e.g. exposure to chemicals, sharp tools, biologicals (feces
and blood) and particulates (feathers)
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A
Comments:
Are flammable or toxic chemicals kept in closed containers when not in use?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A
Comments:
Are chemical piping systems clearly marked as to their content?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A
Comments:
Have standard operating procedures been established, and are they being followed when
cleaning up chemical spills?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A
Comments:
Where needed for emergency use, are respirators stored in a convenient, clean, and
sanitary location?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A
Comments:
Are respirators intended for emergency use adequate for the various used for which they
may be needed?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A
Comments:
Are employees prohibited from eating in areas where hazardous chemicals are
present?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are there written standard operating procedures for the selection and use of respirators
where needed?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are employees instructed on the correct usage and limitations of the respirators?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are the respirators NIOSH - approved for this particular application?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are they regularly inspected and cleaned, sanitized and maintained?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
If hazardous substances are used in the processes, is there a medical or biological
monitoring system in operation?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A
Comments:
Are the employer and employees aware of the Threshold Limit Values or Permissible
Exposure Limits of airborne contaminants and physical agents used in your workplace?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A
Comments:
Have control procedures been instituted for hazardous materials, where appropriate, such
as respirators, ventilation systems, and handling practices?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A
Comments:
Whenever possible, are hazardous substances handled in properly designed and exhausted
booths or similar locations?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A
Comments:
Do you use general dilution or local exhaust ventilation systems to control dusts
(feathers and feces), vapors, gases, fumes, smoke, solvents or mists which may be generated in your
workplace?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Do employees complain about dizziness, headaches, nausea, irritation, or other factors of
discomfort when they are exposed to dusts (feathers and feces), vapors, gases, fumes, smoke, solvents or
mists?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A
Comments:
Is there a dermatitis problem?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A
Comments:
Do employees complain about dryness, irritation, or sensitization of the skin?
[ ]Always
[ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Has employer utilized an industrial hygienist or environmental health specialist to
evaluate the operation?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A
Comments:
If internal combustion engines are used, is carbon monoxide kept within acceptable
levels?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A
Comments:
Is vacuuming used, rather than blowing or sweeping dusts whenever possible for clean-up?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A
Comments:
Are materials which give off toxic, asphyxiant, or anesthetic vapors or fumes, stored in
remote or isolated locations when not in use, e.g. bulk ammonia storage?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A
Comments:
NOISE
Are there areas in the workplace where continuous noise levels exceed 85 dBA?
[ ] Always [ ] Usually [ ] Sometimes [ ] Never [ ] N/A Comments:
Is there an ongoing preventive health program to educate employees in: safe levels of noise exposures; effects
of noise on their health; and the use of personal protection?
[ ] Always [ ] Usually [ ] Sometimes [ ] Never [ ] N/A Comments:
Have work areas where noise levels make voice communication between employees difficult been identified and
posted?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are noise levels being measured using a sound level meter or an octave band analyzer and are records being
kept?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Have engineering controls been used to reduce excessive noise levels?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Where engineering controls are determined not feasible, are administrative controls (i,e., worker rotation)
being used to minimize individual employee exposure to noise?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Is approved hearing protective equipment (noise attenuating devices) available to every employee working in
noisy areas?
[ ] Always [ ] Usually [ ] Sometimes [ ] Never [ ] N/A Comments:
Have you tried isolating noisy machinery from the rest of your operation?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
If you use ear protectors, are employees properly fitted and instructed in their use?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are employees in high noise areas given periodic audiometric testing to ensure that you have an effective
hearing protection system?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Based upon the above observations and analysis, to what degree are health hazards controlled in this
facility?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Electrical Safety
Does the company require qualified persons ("Electricians"), on their maintenance staff, to perform
electrical work at the plant?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Does the company have and use written Electrical Safe Work Practices for electrical operations?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Does the company provide and require the use of personal protective equipment and insulated tools during
electrical operations?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are motor control areas and electrical switching areas protected from unauthorized employee access?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Does the company require that permanently installed equipment and motors be powered with permanent wiring
(protected in a raceway or conduit) versus using flexible cords and cables?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Does the company require that when flexible cords and cables are used to power temporary equipment that they be
protected from accidental damage, abrasions, or being caught in moving equipment and conveyors?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Does the company require that flexible cords and cables:
- not be spliced or repaired:
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
- be connected to devices and fittings in order to provide strain relief at the terminals/ joints:
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
- not be used as a substitute for permanent wiring:
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
- not be run through holes in walls, ceilings, floors; not through doorways and windows:
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
- not be run behind walls, ceiling, or floors and not attached to the building surfaces:
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Does the company NOT allow the use
of Type TC power and control tray cable to be used as
pendant wiring to equipment, and only installed in cable trays, raceways and along a messenger wire?
[ ]Always [ ]Usually [ ] Sometimes [ ]Never [ ]N/A Comments:
Does the company require that electrical rooms, motor control areas, and electrical switching areas be clear of
stored materials?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Does that company require that all electrical equipment, disconnects, circuit breakers and load centers be
identified as to the purpose of the equipment?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Does the company require that all equipment installed in the plant be capable of being locked out during
service, maintenance and sanitation operations?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Does the company ensure that all circuits, equipment, motors, and electrical devices are grounded?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
If plastic conduit to be used, does the company ensure that a separate grounding conductor is installed in the
circuit?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Does the company ensure that energized, live parts of equipment, motors, electrical wiring and electrical
devices are protected from accidental employee contact or exposure?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Does the company ensure that boxes containing wiring are covered and protected from damage?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Does the company ensure that electrical equipment installed in wet or damp locations is approved for that
use?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Does the company ensure that electrical equipment installed in hazardous locations at the plant is
intrinsically safe and approved for the hazardous location?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Based upon the above observations and analysis, to what degree are the electrical related hazards controlled in
this facility?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Confined Space
Does the employer provide and use a written confined space program and procedure for all operations involving
potential confined space hazards?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are potential confined space hazards identified at the workplace, e.g. icehouses, pits, etc.?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Where confined space hazards exist and outside contractor employees will enter the spaces, does the host
employer properly apprise the contractor of hazards and precautions, coordinate entry operations and debrief
the contractor as necessary?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Where confined space hazards exist, are employees made aware of the associated hazards and requirements by
posting or other means?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are entry permits required prior to employees working in a permit space?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are permit-required confined spaces made into "non-permit" confined spaces?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Does the company use "alternative methods" to eliminate all potential atmospheric hazards in the
confined space?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Does the company ensure that there is a properly trained and empowered entry supervisor, who enforces and
periodically checks that the permits and the program are followed?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Is plant entry to permit-required confined spaces restricted to only authorized employees in the plant?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Does the company provide and use calibrated monitoring equipment for testing confined spaces?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Does the company properly sample atmospheres in confined spaces (i.e. oxygen content first, flammable
atmosphere second and last for toxic chemicals)?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Is monitoring performed prior to and while employees are involved in confined space operations?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Is visual and/or verbal contact maintained with employees, by means of a properly trained attendant, that enter
a permit-required confined space?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Is the lighting in the confined space 1) sufficient to safely perform the work and 2) sufficient to maintain
visual contact when appropriate; and 3) does it meet electrical code if the confined space presents a flammable
vapor or combustible dust hazard?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Is a rescue system in place at the plant for those employees that enter and perform work in permit-required
confined spaces?:
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Does the employer provide rescue equipment at the workplace for those employees that enter and work in
permit-required confined spaces?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Does the employer perform practice confined space entry and rescue operations sometime during a 12 month
period, during which they remove a "practice victim" from the confined space?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Does the company ensure that each member of a confined space rescue team be trained in first aid and CPR?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Were all involved employees properly trained in the company's program, procedures and hazards associated with
operations in confined spaces?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Based upon the above observations and analysis, to what degree is the hazard of confined spaces controlled in
this facility?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ] N/A Comments:
Emergency Preparedness
Does the company have over-the-threshold quantities of highly hazardous chemicals for process safety management
provisions to apply, e.g. 10,000 pounds ammonia or 1500 pounds chlorine?
[ ] Yes [ ]No
Has the company gathered process safety management information from appropriate sources for covered
chemicals?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Has the company completed process hazard analysis for covered processes?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are specific operating procedures in writing covering startup, normal operations, safe operating limits and
emergency shutdowns?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ] N/A Comments:
Have employees been trained on operating procedures and process hazards?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Is there a written program with schedules and procedures for maintenance of piping, pressure vessels, valves,
relief valves, controls and alarms?
[ ]Always [ ]Usually [ ] Sometimes [ ]Never [ ]N/A Comments:
Are incidents involving highly hazardous chemicals investigated, documented and resolved in a timely
manner?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are designated employees trained annually on the use of portable fire extinguishers?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are portable fire extinguishers visually checked monthly?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Does the written emergency action (evacuation) plan cover designated escape routes, procedures for critical
employees who remain behind, headcount procedures, means of emergency notification and alarm systems?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Have employees been trained on the emergency action plan?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Does the facility have an audible alarm system capable of being perceived above the ambient noise level at all
workstations?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Is the alarm system functionally tested on an annual basis?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Is a continuous, unobstructed way of exit travel maintained from all workstations in the buildings?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Is the width of all egress paths sufficient (i.e. 22 inches per 100 people) for the number of people who may
utilize such paths?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Is there a minimum of six foot eight inches of headroom from any projects along the path of the egress from all
workstations?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are all exits marked with an exit sign and illuminated by a reliable light source?
[ ]Always [ ]Usually [ ] Sometimes [ ]Never [ ]N/A Comments:
Are the direction to exits, when not immediately apparent, marked with visible signs?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are exit signs provided with the word "EXIT" in lettering at least 5 inches high and the stroke of
the lettering at least 1/2-inch wide?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are exit doors side-hinged?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Do all exits open in the direction of exit travel and kept free of obstructions and impediments to instant
use?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are there sufficient exits to permit prompt escape in case of emergency?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are doors, passageways or stairways, that are neither exits nor access to exits, and which could be mistaken
for exits, appropriately marked "NOT AN EXIT," "TO BASEMENT," "STOREROOM,"
etc.?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Where exit doors open directly onto any street, alley or other area where vehicles may be operated, are
adequate barriers and warnings provided to prevent employees from stepping into the path of traffic?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are at least two means of egress provided from elevated platforms, pits or rooms where the absence of a second
exit would increase the risk of injury from hot, poisonous, corrosive, suffocating, flammable, or explosive
substance?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Where ramps are used as part of required exiting from a building, is the ramp slope limited to 1 foot vertical
in 12 feet horizontal?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Are doors on cold storage rooms provided with an inside release mechanism which will release the latch and open
the door even if it's padlocked or otherwise locked on the outside?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Based upon the above observations and analysis, to what degree is the potential for catastrophe controlled in
this facility?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Safety and Health Program
Rate the employer safety and health program in terms of implementation of the elements of:
Management commitment and employee involvement
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Hazard recognition and analysis
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Hazard control
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Employee information and training
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
List the three hazards which in your opinion are the most significant at the plant?
1.
2.
3.
Do employees live in employer provided housing?
[ ] Yes [ ] No
Rate the employer provided housing facilities as generally clean, sanitary and livable?
[ ]Always [ ]Usually [ ]Sometimes [ ]Never [ ]N/A Comments:
Does the employer utilize contractors to perform hazardous procedures?
[ ] Yes [ ] No
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