Safety Assessment Tool

University of Notre Dame Safety Assessment Program
Safety Assessment Checklist
Aerial Lif
Q# Question Weight Requirement
Is fall arrest equipment worn by persons working from aerial lifts

1.1 3 1926.453(b)(2)(v)
and other similar mobile equipment used to elevate workers?
Are pre-use equipment inspections and workplace inspections

1.2 2 1926.453 (b)(2)(xii)
conducted and documented when using aerial and scissor lifts?
1.3 Are personnel trained prior to operating an aerial or scissor lift? 3 1926.454
1926.454
1.4 Are scaffolds inspected by a competent person before use? 2 29 CFR 1926.451(g)(2)
1.5 Are personnel who work on scaffolds trained? 3 1926.454(a)
1.6 Other 1 N/A
Asbestos
Have all affected employees who may in the course of

2.1 employment contact ACMs and PACMs completed asbestos 3 1910.1001(j)(7)(iv)
awareness training?
2.2 Are areas containing ACMs properly labeled? 3 1910.1001(j)(5)

2.3 Other 1 N/A
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Battery Charging
Do truck battery charging areas at the site meet the following

requirements?
• Areas are designed and properly equipped;
3.1 • Charging equipment is protected from being struck by trucks; 3 29 CFR 1910.178(g)(1)
and
• Workers are required to wear goggles, face shield, and

chemically-resistant aprons and gloves when adding water or acid
to wet cell batteries.
Are precautions taken to prevent open flames, sparks, or electric 29 CFR 1910.178(g)
3.2 2
arcs in battery charging areas? (11)
3.3 Other 1 N/A
BBP & Sharps

Is it prohibited to eat, drink, smoke, apply cosmetics, and handle 29 CFR 1910.1030(d)
4.1 contact lenses in work areas where the potential exists for 2 (2)(ix)
exposure to bloodborne pathogens?
Are containers used for sharps disposal easily accessible and
located in the area where sharps are used or can be reasonably 29 CFR 1910.1030(d)
4.2 anticipated to be found? 2 (4)(iii)(A)(2)
Are full containers disposed by RMS?
Revised 8/15/2018 2 of 141

Is contaminated laundry handled as little as possible with a

minimum movement?
Is contaminated laundry placed and transported in bags or 29 CFR 1910.1030(d)

containers labeled with the biohazard symbol or colored red? (4)(iv)(A)
4.3 3 and
Is wet contaminated laundry placed and transported in bags or 29 CFR 1910.1030(d)
containers that will prevent soak-through and/or leakage of fluids (4)(iv)(A)(2) & (3)
to the exterior?
Is PPE used when handling contaminated laundry?
Within 10 days of initial assignment, is the hepatitis B vaccination

series made available to persons whose job is reasonably 29 CFR 1910.1030(f)
4.4 3
anticipated to have contact with blood or other potentially (2)
infectious materials
Have persons who refused to take the hepatitis B vaccination 29 CFR 1910.1030(f)
4.5 series signed a statement to that effect following the form 2 (2)(iv)
prescribed by the OSHA standard?
Are individuals who are reasonably anticipated to have contact

with blood or other potentially infectious materials in the course
of their work or student activities provided training on
bloodborne pathogens initially and annually thereafter? 29 CFR 1910.1030(g)
4.6 2 (2)
Is bloodborne pathogen training provided before or at the time of
initial assignment where contact with blood or other potentially
infectious materials is possible?
4.7 Other 1 N/A
Chemical Exposure
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Have personnel received training on incident reporting and their

5.1 2 29 CFR 1910.1020 (e)
right of access to relevant exposure and medical records?
Are containers of hazardous chemicals is labeled, tagged or

marked with the appropriate information?
Each container of hazardous chemicals is labeled with the

following information: (i) identity of the hazardous chemical; and,
(ii) appropriate hazard warnings, or alternatively, words, pictures, 29 CFR 1910.1200 (f)
5.2 2
symbols, or combination thereof, which provide at least general (1)
information regarding the hazards of the chemicals, and which, in
conjunction with the other information immediately available to
employees under the hazard communication program, will
provide employees with the specific information regarding the
physical and health hazards of the hazardous chemical.
5.3 Is a documented inventory of all chemicals taken annually? 2 1910.1200(e)(1)(i)
Are safety data sheets (SDS) available for each used in the
5.4 2 29 CFR 1910.1200 (g)
workplace?
Revised 8/15/2018 4 of 141

5.5 Are employees provided hazard communication training? 3 29 CFR 1910.1200 (h)
Are personnel trained on hazardous chemicals in their work area

at the time of their initial assignment, and whenever a new
5.6 2 29 CFR 1910.1200 (h)
chemical hazard the employees have not previously been trained
about is introduced into their work area?
Are flammable or combustible liquids stored in proper containers?

The containers must comply with the applicable design, 29 CFR 1910.106 (d) &
5.7 construction and capacity requirements. All containers of 3 (e)
flammable or combustible liquids are stored in storage cabinets or
in properly designed and constructed inside storage rooms.
Have methods been developed to inform employees of the 29 CFR 1910.1200(e)

5.8 3
hazards of non-routine tasks? (1)(ii)
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5.9 Are incompatible chemicals/wastes segregated appropriately? 1 None
Is dry ice stored in a well-ventilated location (no walk-in freezers

or coolers) and placed in a container designed for the storage of
5.10 dry ice and are dry ice baths open to the atmosphere? Is 1 Dry Ice Procedure
unneeded dry ice properly disposed (never placed in sink, toilet,
drain, trash/garbage)?
Have personnel who ship packages containing dry ice been

5.11 1 Dry Ice Procedure
trained on DOT/IATA requirements?
5.12 Other 1 N/A
Compressed Gas
Do compressed gas cylinders meet the following requirements (as

applicable)?
• Cylinders are secured at all times to prevent tipping, falling, or

rolling;
• Safety caps replaced when not in use
6.1 • Cylinders are only transported using carts or other devices 2 29 CFR 1910.101
specifically designed for moving cylinders;
• Cylinder contents must be clearly labeled;
• Cylinders are kept shaded from direct sunlight;
• Oxygen cylinders are separated from fuel-gas cylinders;
• Cylinders and components are kept free from oil and grease;
• Cylinders are equipped with pressure relief valves;
6.2 Other 1 N/A
Revised 8/15/2018 6 of 141

Cranes/Hoists
Are visual inspections and functional checks conducted prior to

7.1 2 29 CFR 1910.179(j)(2)
usage? Are these documented on an inspection sheet?
Are documented inspections conducted of cranes, hoists, ropes,

7.2 chains, slings by by qualified personnel (e.g., outside vendor), 2 29 CFR 1910.179(j)(3)
including initial load testing?
Are all under-hook lifting attachments in safe working order,

7.3 properly stored, and thorough inspection conducted at least once 1 29 CFR 1910.184(e)(3)
every 12 months?
Are personnel informed that loads shall not be moved over 1910.179(n)(3)(vi)
7.4 people and tag lines shall be used on loads that must be guided 3
into position? 29 CFR 1926.554(a)(4)
Are crane, hoist operators and maintenance personnel properly

7.5 trained in safe operating procedures and equipment inspections 3 29 CFR 1910.179(b)(8)
requirements?
Is the rated load of the crane plainly marked on each side and is
7.6 1 29 CFR 1910.179(b)(5)
the marking clearly legible from the ground or floor?
7.7 Other 1 N/A
Confined Space Entry
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Before entry operations begin, has a permit been properly

completed?
8.1 Has the permit been cancelled at the end of the CSE, duration not 3 1910.146(e) & (d)(10)
exceeding the shift?
Are permits retained for recordkeeping?
Is signage present at the CS that informs employees of permit

8.2 3 1910.146 (c)(2)
spaces?
Has the space been been tested to determine if acceptable enter
8.3 3 1910.146(c)(5)(i)
conditions exist prior to entry?
Are attendants assigned and stationed outside the confined space
8.4 3 1910.146(d)(6)
for the duration of the entry operation?
Is the confined space sufficiently isolated to prevent unauthorized
8.5 3 1910.146(c)(3)
entry?
Have entrants been provided the opportunity to observe any
8.6 3 1910.146(d)(3)(ii)
monitoring or testing of atmospheres?
8.7 Are competent persons, attendants and entrants trained? 3 1910.146 (g)(1)
8.8 Are affected employees trained in the CS hazards and program? 2 1910.146 (g)(2)
8.9 Is there a system for summoning rescue and emergency services? 3 1910.146(d)(9)
If confined space has been reclassified to a non-permitted space

8.10 is there documentation of a reclassification form indicating that all 3 1910.146(c)(7)
the hazards have been eliminated?
When contractors are performing CS entry, are documented Confined Space

8.11 Contractor Confined Space Information forms retained on file as 3 Procedure
well as completed entry permits?
8.12 Other 1 N/A
Combustible Dust
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Is there a housekeeping program to manage the dust

9.1 accumulations to less than 1/32nd of an inch (i.e. thickness of 2 BMP
paper clip)?
Are the cleaning methods NOT dry methods such as using brushes
9.2 or compressed air that can disperse dust in the area? 2 BMP
9.3 Are personnel trained of the combustible nature of the dust? 2 BMP
9.4 Other 1 N/A
Emergency Action Plan

Is a written emergency action plan available that includes the
following items?
a. Emergency escape procedures, signals, and routes
b. Procedures for designated employees who must remain in the
facility to shut down equipment before they evacuate
c. Procedures to account for all building occupants
d. Rescue and medical duties
e. Preferred mechanisms for building occupants to report
10.1 emergencies 1 29 CFR 1910.38(c)
f. Names and job titles of people who can be contacted for more
information regarding evacuation plans
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Is the emergency action plan made available to building 29 CFR 1910.38(b) and
occupants and have all employees been trained on the plan? Have
10.2 2 29 CFR 1910.38€ and
designated employees assigned to help with the safe and orderly
(f)
evacuation of all building occupants been trained?
Are exit signs clearly visible and illuminated and are exits clear
10.3 and unobstructed? 2 29 CFR 1910.36(b)(4)
Are doors, passageways or stairways that are neither exits nor a 2
way to an exit, and which can be mistaken for an exit, marked
10.4 with a sign reading "Not An Exit" or similar designation? 29 CFR 1910.36(b)(5)
Is the vertical clearance between sprinklers and material below at 3 29 CFR 1910.159(c)
10.5 least 18 inches? (10)
Is the fire extinguisher mounted and inspected monthly? Is access 2
10.6 to the fire extinguisher unobstructed? Is fire extinguisher within 1910.157(c)(1) and
the annual inspection date. 29 CFR 1910.157(e)
10.7 Are personnel trained annually on fire extinguisher use? 29 CFR 1910.157(g)(1)
Are suitable facilities for quick drenching or flushing of the eyes 2

10.8 and body available in work areas where the eyes or body may be 29 CFR 1910.151(C)
exposed to corrosive materials?
Is there unobstructed access to the safety shower, and annual 2

10.9 inspection by facilities is documented? 29 CFR 1910.151(c)
Is there unobstructed access to the eyewash station and 2
10.10 inspected monthly? 29 CFR 1910.151(c)
10.11 Other 1 N/A
Electrical
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29 CFR 1910.303(g)(1)
Where in use, are extension cords in safe working condition and and 1926.405(g)(1)
used properly for no more than 90 days? (iii)
11.1 3
Must not be: (a) attached to building surfaces; (b) concealed; (c) 29 CFR 1910.305(a)(2)
run through holes in walls, ceilings, or floors; or (d) run through (i) and 1926.405(a)(2)
doorways, windows, or similar openings (i)
11.2 Are all unused openings in cabinets, junction boxes, and fittings 2
29 CFR 1910.305(b)
effectively closed? (1)
Are all disconnecting switches, electric boxes, cabinets, circuit OSHA 1910.303 ('e)
11.3 breaker panels, etc., labeled to indicate their use, voltage or 1 and
equipment served? 1910.303 (f)
Are extension cords or power strips NOT plugged into one

11.4 another (daisy chained) and NOT used to power appliances (e.g., 2 29 CFR 1910.303(b)(2)
microwave ovens, refrigerators)?
Where lights are used for general illumination, are they protected OSHA 1910.305(a)(2)
11.5 from accidental contact by a fixture or guard and without 1 (ix) and 1910.305(j)(i)
damage?
Are receptacles or switches in good condition? Are electrical 29 CFR 1910.303(b)(7)
11.6 3
pendant drops properly designed? (iv)
Are receptacles on rooftops, in outdoor areas, or near water
11.7 2 NFPA 70 210.8(B)
sources GFCI protected?
11.8 Is electric equipment operating at 50 volts or more guarded? 3 29 CFR 1910.303(g)(i)
29 CFR 1910.303(g)(1)
11.9 Are electrical rooms free from being used for storage? 2 (ii)
Are electrical panels unobstructed (clear area at least 30" wide x

11.10 2 29 CFR1910.305 (d)
36" deep)?
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Are only qualified persons permitted to work on energized electric 3 29 CFR 1910.333(c)(2)
circuit parts (>50 volts) or equipment that has not been and 29 CFR
11.11' deenergized? 1910.332(b)
Are employees provided ground-fault circuit interrupter (GFCI) 2 29 CFR 1926.404(b)(1)

11.12 protection while using powered equipment? (ii)
Are employees who work in areas where electrical hazards exist 3 29 CFR 1910.335(1)(v)
11.13 provided with and required to use PPE?
Are insulating equipment (gloves, mats, etc.) inspected before 2 29 CFR 1910.137(c)(2)
11.14 each day’s use and electrically tested every 6 months for gloves? (viii)
11.15 Other 1 N/A
E-Waste

Are e-wastes properly labeled or marked to identify "Electronic
12.1 2 329 IAC 16-3-1
Waste"?
12.2 Have personnel who handle e- wastes been trained? 2 329 IAC 16-8-1
Fall Protection
Is every open-sided platform 4 feet or more, guarded by a 29 CFR 1910.23(c)(1)

13.1 3
standard railing and toe board? (i) - (iii)
Are stairs with four or more risers, equipped with standard stair
13.2 3 29 CFR 1910.23(d)(1)
railings or standard handrails?
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Are load limits posted on elevated floors, mezzanines, and other

13.3 1 29 CFR 1910.22
elevated storage areas?
Do covers protect employees on a walking and working surface 29 CFR 1926.501 (b)
13.4 3
from tripping in or stepping into holes (including skylights)? (4)(ii)
29 CFR 1926.501(b)(1)
Do guardrail systems or personal fall arrest systems protect
13.5 employees when they work on unprotected sides and edges of 3 29 CFR 1926.501(b)(8)
walking and working surfaces or into dangerous equipment? (i)
Have all employees who access rooftop areas been informed of

required access procedures and signed and dated the posted Fall Protection
13.6 3
hazard assessment? If a hazard assessment is not posted, do Procedure
employees refrain from accessing the roof?
Are provisions made for prompt rescue in the event of a fall, or 29 CFR 1926.502 (d)
13.7 3
are employees able to rescue themselves? (20)
Have all employees who use fall protection completed fall

13.8 3 29 CFR 1926.503(b)(1)
protection training?
Is there a documented inventory of Personal Fall Arrest Systems? 29 CFR 1926.502

Are personal fall arrest systems inspected before each use and (d)(21)
13.9 periodically by a Competent Person and documented? Are 2
defective components removed from service? Is use of body belts 29 CFR 1926.502(d)
prohibited?
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13.10 Are portable ladders inspected before use? 2
13.11 Other 1 N/A
FIFRA
Does the facility use registered pesticides in a manner consistent 2 7 U.S.C.136(a)(2)(G)

14.1 with the pesticide's labeling?
Do personnel who use restricted use pesticides apply under the 3 40 CFR 152.175
14.2 direct supervision of a certified applicator? 40 CFR Part 171
14.3 Other 1 N/A
Guarding/Tools/Air
Are all machines guarded to protect the operator and other

people in the machine area from hazards such as those created by
15.1 3 29 CFR 1910.212(a)(1)
point of operation, ingoing nip points, rotating parts, flying chips,
and sparks?
Are shaft ends that project more than 1/2 of the diameter of the
15.2 2 OSHA 1910.219(c)(4)
shaft guarded by nonrotating caps or safety sleeves?
Are guards firmly secured, not easily removable and free from
15.3 2 OSHA 1910.212(a)
burrs and sharp edges?
Is all machinery designed for a fixed location securely anchored to
15.4 2 29 CFR 1910.212(b)
prevent "walking" or "moving?"
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Metal or
Are all machines and equipment requiring the presence of an
15.5 1 Woodworking Shop
operator not left unattended while in operation or still in motion? Policy
Are abrasive wheel tools equipped with proper guards, guard OSHA 1910.215(a)
15.6 properly adjusted, and the wheel free of damage and ring-tested 2 and 1910.215(d)(1)
prior to mounting?
Are all machine controls clearly marked to indicate their intended

operation? Are machines that are equipped with emergency stop
15.7 1 None
buttons have the e-stops located in close proximity to the
operator and red in color?
Are all fans less than 7 feet from the floor equipped with guards
15.8 1 OSHA 1910.212(a)(5)
that have openings no larger than one-half (1/2) inch?
Are those who operate machines wearing the appropriate PPE

15.9 and have no loose fitting clothing, hair or jewelry that could 3
become entangled?
Are hand and portable power tools are in good condition and 29 CFR 1910.242 & .
15.10 properly guarded, including tools and equipment which may be 3 243
furnished by employees.
Is it prohibited to use compressed air for cleaning purposes

15.11 except when it is reduced to less than 30 p.s.i. and then only with 3 30 CFR 1910.242(b)
effective chip guarding and personal protective equipment.
15.12 Other 1 N/A
Hazardous Waste
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Are periodic inspections of satellite storage areas being conducted Hazardous Waste
16.1 2
and documented? Procedure
Are containers clearly labeled with the words "Hazardous Waste" Hazardous Waste
16.2 with each constituent noted on the label, in good condition (leak- 3 Procedure
proof and clean) and kept securely closed when not in use?
Are wastes stored in containers that have secondary containment

16.3 large enough to contain 10% of total volume of container or 100% 2 Haz Waste Proc.
of volume of largest container, whichever is greater?
Hazardous Waste
16.4 Have personnel who handle hazardous wastes been trained? 2 Procedure
Is the quantity of waste less than 55 gallons or less than 1 quart Hazardous Waste
16.5 3
for acutely toxic waste? Procedure
Are contaminated rags/wipes saturated with solvents properly Hazardous Waste

16.6 stored in an approved metal can with a tight-fitting lid and 2 Procedure
properly labeled as "Hazardous Waste Contaminated Rags"?
16.7 Other 1 N/A
Heat/Cold
Are personnel trained in heat and cold stress hazards and

17.1 2 BMP
methods to take to prevent injury or illness?
Are personnel provided fluids and/or administrative controls, e.g.,

17.2 job rotation or more frequent breaks to alleviate the extreme 2 BMP
temperatures?
Revised 8/15/2018 16 of 141

17.3 Other 1 N/A
Heavy Mobile Equipment
Does equipment in which the operator cannot directly or by

18.1 mirror or other effective device see immediately behind the 3 BMP
machine have an automatic audible warning device?
Does equipment used at night have and use lights to adequately

18.2 illuminate the direction of travel, working area immediately 3 BMP
around the equipment and cab instruments?
18.3 Are operating controls identified to show the function they serve? 2 BMP
Are windshields, side and rear windows, and rear-vision mirrors

18.4 maintained to provide clear vision to the operator for the safe 3 BMP
operation of the equipment?
If work is being performed and elevated over the cab, is the cab
18.5 3 BMP
protected by an adequate overhead guard?
Are Rollover Protective Structures (ROPS) installed on any mobile

18.6 3 BMP
equipment where the possibility of a rollover exists?
Have all authorized drivers been properly trained on each piece of

18.7 2 BMP
equipment they are permitted to operate?
18.8 Other 1 N/A
Hot Work
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Hot Work Procedure

Are Hot Work Permits obtained for hot work activities in non-
19.1 3
designated hot work areas? 29 CFR 1910.252
Is the equipment being worked on thoroughly cleaned / purged of

flammable or combustible materials? Hot Work Procedure
19.2 3
Are all movable fire hazards removed (>35') and all non-movable 29 CFR 1910.252(a)(1)
objects and adjacent employees protected by barriers, including
outdoor areas?
Is suitable fire extinguishing equipment maintained in a state of Hot Work Procedure

constant readiness and used by fire watchers?
19.3 3 29 CFR 1910.252(a)(2)
Building fire extinguishers shall not be used for fire watch. (ii)
Hot Work Procedure

19.4 Are firewatchers required and used during hot work activities? 3 29 CFR 1910.252(a)(2)
(iii)[A][1]-[4]
Hot Work Procedure

Is the fire watch maintained for at least 30 minutes after
19.5 3
completion of the hot work? 29 CFR 1910.252(a)(2)
(ii)[B]
Is PPE provided to individuals performing the hot work activity?
19.6 Do welding or cutting goggles, helmets and face shields employ 3 29 CFR 1910.252(b)(2)
the correct filtered lens (shade number) for the welding
operation?
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Are gas cylinders properly labeled, transported and separated

(empties from non-empties), associated piping properly secured,
and safety caps replaced when not in use? 29 CFR 1910.253(b)
19.7 2 (1)-(4)
Are welding hoses, leads, or cables free of damage and kept clear
of passageways, ladders and stairways?
Have employees involved in Hot Work tasks (persons performing

work, Fire Watches, etc.) been trained in Hot Work Employee
19.8 3 Hot Work Procedure
training, Hot Work Fire Watch and Hot Work Permit Issuer
training?
Is the designated hot work area (permit not required) maintained

with proper housekeeping?
19.9 3 Hot Work Procedure
Combustibles kept 35' away, fire extinguishing equipment present
and maintained, signage posted?
19.10 Other 1 N/A
Housekeeping

Are storage areas kept free from accumulation of materials that
20.1 constitute hazards from tripping, fire, explosion, or pest 2 29 CFR 1910.22
harborage?
Are aisles and passageways kept clear and in good repairs, with no
20.2 2 29 CFR 1910.22
obstructions across or in aisles that could create a hazard?
Are all areas, passageways, storerooms, and service rooms kept

20.3 2 29 CFR 1910.22
clean and orderly and in a sanitary condition?
20.4 Other 1 N/A
Lif Trucks
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Are battery charging installations located in areas designated for 29 CFR 1910.178(g)(1)
21.1 that purpose? If maintenance is performed on batteries, are 2 & (2)
facilities provided for flushing and neutralizing spilled electrolyte?
Have lift truck and/or powered pallet operators completed 29 CFR 1910.178(l)(1)
21.2 2
training? (i)
Are evaluations performed of each powered industrial truck 29 CFR 1910.178 (l)(4)
21.3 2
operator's performance at least once every three years? (iii)
Are the fork trucks inspected prior to use each shift and
21.4 2 29 CFR 1910.178(q)(7)
inspections properly documented?
If lift truck attachments are used (e.g., container handlers, carton

clamps, barrel clamps, etc.), have operators been trained on its
21.5 2 29 CFR 1910.178(a)(5)
operation and limitations and has the trucks data plate been
updated to include details of attachment?
21.6 Other 1 N/A
LTT
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Are equipment-specific energy control procedures available for

each piece of equipment that address the elements listed below?
• Identification of the equipment and/or task

• Type and magnitude of all hazardous energy sources
• Listing of all applicable energy isolation devices
• Specific steps to obtain zero energy state 29 CFR 1910.147(c)(4)
22.1 3
• Specific steps for verifying energy control including the release (i)
of stored energy
Written procedures are NOT required for cord and plug connected
equipment and pieces of equipment that have single, readily
identifiable energy isolation devices if there is no potential for
stored energy after shut down.
Are periodic audits conducted to ensure authorized persons are

following prescribed energy control procedures and that energy
22.2 3 29 CFR 1910.147(c)(6)
controls are being utilized properly?
29 CFR 1910.147(c)
22.3 Have authorized persons been trained? 3 (7(i)
Have affected employees been trained in the purpose and use of 29 CFR 1910.147(c)
22.4 3
the energy control procedure. (7(i)
Are locks, tags, or other hardware provided for isolating, securing 29 CFR 1910.147(c)(5)
22.5 and blocking of machines or equipment from energy sources? 3 (i)
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Are lockout and tagout devices red in color for personal locks,
blue for group lockout and green for long term equipment
isolation? Are locks prohibited from use for other purposes,
29 CFR 1910.147(c)(5)
22.6 capable of withstanding the environment to which they are 3 (ii)
exposed, standardized, i.e., color, shape, size, paint and format,
and substantial enough to prevent removal without the use of
excessive force?
Are locks equipped with tags that read “Do not start”, “Do not 29 CFR 1910.147(c)(5)
22.7 open”, “Do not close”, “Do not energize”, or ‘Do not operate” and 2 (iii)
identify lock owner?
Do authorized persons verify that de-energizing has been

22.8 effective by attempting to start the equipment and release 3 1910.147(c)(4)(ii)(D)
residual energy before starting servicing or maintenance work?
Do procedures exist for removing and transferring locks and tags?

22.9 Are documented emergency lock removal forms completed in 3 1910.147(c)(4)(ii)(C)
such situations?
22.10 Other 1 N/A
MMH
Is proper lifting training provided for personnel who routinely lift

23.1 1 BMP
>35 lbs.
23.2 Other 1 N/A
Motor Vehicle Use/DOT
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Have employees who operate motor vehicles transporting

24.1 3 49 CFR 177.816
hazardous materials been properly trained?
24.2 Are vehicles inspected prior to use? 2 49 CFR 177

24.3 Other 1 N/A
Noise
Is annual Hearing Conservation training provided to all employees Hearing Conservation

25.1 1
in the HCP? Program
Have all operations or equipment believed to exceed 85 dBA TWA Hearing Conservation
25.2 1
been measured to determine noise levels? Program
Is hearing protection provided and required for employees in the Hearing Conservation
25.3 2
hearing conservation program? Program
Do personnel who are in the hearing conservation program Hearing Conservation

25.4 1
complete annual audiograms? Program
For areas exceeding 85 dBA, are the properly labeled and Hearing Conservation
25.5 2
identified as areas requiring hearing protection? Program
25.6 Other 1 N/A
PPE

26.1 Has a PPE hazard assessment been completed? 2 29 CFR 1910.132(d)
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26.2 Is training provided to each employee that is required to use PPE? 2 29 CFR 1910.132(f)(1)
26.3 Is the PPE provided at no cost to employees? 1 29 CFR 1910.132(3)(h)
Are suitable eye protection (ANSI Standard Z87.1) required where

26.4 operations present the hazard of flying particles, liquid chemicals, 2 29 CFR 1910.133(a)(1)
acids or caustic liquids, chemicals, etc?
Are employees required to wear an approved protective hard hat

26.5 (ANSI Z89.1) when working in areas where there is a potential for 2 29 CFR 1910.135(a)(1)
injury to the head from falling objects?
Are employees required to use protective footwear, (ANSI Z41)

when working in areas where there is a danger of foot injuries
26.6 2 29 CFR 1910.136 (a)
due to falling or rolling objects, or objects piercing the sole, and
where employee’s feet are exposed to electrical hazards?
Are employees required to use appropriate hand protection when

hands are exposed to such hazards as those from skin absorption
26.7 of harmful substances, severe cuts or lacerations, severe 2 29 CFR 1910.138 (a)
abrasions, punctures, chemical burns, thermal burns, and harmful
temperature extremes?
26.8 Are respirator users trained? 2 29 CFR 1910.134
For employees who voluntarily wear a respirator, have they

26.9 1 29 CFR 1910.134
completed a Voluntary Use Form?
26.10 Other 1 N/A
Pressure Vessels
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Are boilers and pressure vessels inspected by competent persons Boiler and Pressure
27.1 and listed on the inventory maintained by Facilities, Design and 3 Vessel Regulations
Operations division? (680 IAC 2)
If a deficiency is noted during an inspection, is the equipment Boiler and Pressure

27.2 labeled as "Do Not Use" and taken out of service until the 3 Vessel Regulations
deficiency is corrected through corrective action? (680 IAC 2)
Do compressed air systems at the site meet following

requirements (as applicable)?
• Air receiver tanks are equipped with a pressure gauge, relief

valve of adequate capacity, and a drain at the lowest level to allow
for removal of accumulated oil and water.
• Air compressors are not used to generate breathing air for
supplied air respirators without the written permission from RMS.
• Flammable liquids such as solvents are not stored or used within
35 feet of an air compressor. Boiler and Pressure
• Compressed air is not used to clean clothing or body parts.
27.3 3 Vessel Regulations
• Air nozzles used for compressed air cleaning is specifically (680 IAC 2)
designed to reduce air consumption and minimize excessive noise
levels. Nozzles are able to reduce air pressure to less than 30 psi
(2 bar) if the nozzle tip is blocked.
• Worm gear clamps or radiator-style clamps are not used to
secure hose fittings to compressed air hoses. Ear clamps, crimp
sleeves, ferrules, or press-on fittings rated for the maximum
allowable working pressure are used.
• Compressed air hose couplings used for cleaning nozzles or
compressed air tools are equipped with locking sleeves to prevent
accidental disconnection.
Revised 8/15/2018 25 of 141

Is Pressure Vessel/Systems Safety training provided for employees

who operate air compressors that includes the following topics?
27.4 • Start-up and shutdown procedures 2 BMP

• System parameters and actions to take when performance
varies from those parameters
• Inspection requirements
27.5 Other 1 N/A
Radiation (Ionizing)
Has the use of radiation in this area been approved by the

28.1 2 Radiation License
campus Radiation Control Committee?
Is there documentation that all personnel working in the area

28.2 where the radioactive materials are used and/or stored have been 1 Radiation License
appropriately trained?
Are the records for radioactive material use, contamination

28.3 surveys, and inventory properly updated and maintained for 2 Radiation License
inspection?
Is the NRC Form 3 "Notice to Employees" posted. In areas using

28.4 machine produced radiation (x-ray machines) is ISDH Board Form 1 Radiation License
X on or near the unit or its control panel.
Is the Radiation Safety Manual available in the room and have
28.5 1 Radiation License
personnel been informed of its location?
28.6 Other 1 N/A
Radiation (Non-Ionizing)
Revised 8/15/2018 26 of 141

ND RAD01
Have all lasers and laser areas been approved by the campus
29.1 2 Laser/UV Light Source
Laser Safety Officer? Manual
ND RAD01
Are laser use areas identified by the proper signage, including
lighted signs for Class 4 lasers? Manual
ND RAD01
29.3 Is there documentation of Laser Safety training? 2 Laser/UV Light Source
Manual
ND RAD01
29.4 Is the appropriate Laser Safety Eyewear available? 2 Laser/UV Light Source
Manual
ND RAD01
Have all laser users undergone a baseline eye exam as required by
the Laser Safety Manual? Manual
ND RAD01
Is the Laser Safety Manual available in the room and have
personnel been informed of its location? Manual
29.7 Other 1 N/A
Service Tires
Is there a program to train all employees who service rim wheels

30.1 in the hazards involved in servicing those rim wheels, and the 2 29 CFR 1910.177(c)(1)
safety procedures to be followed?
Does the employer ensure that no employee services any rim

wheel unless the employee has been trained and instructed in 29 CFR 1910.177(c)(1)
30.2 correct procedures of servicing the type of wheel being serviced 3 (i)
and in the safe operating procedures described in paragraphs (f)
and (g) of 29 CFR 1910.177?
Revised 8/15/2018 27 of 141

Does the employer ensure that each employee demonstrates the

30.3 2 29 CFR 1910.177(c)(2)
ability to service rim tires safely?
Does the employer evaluate each employees' ability to perform
30.4 2 29 CFR 1910.177(c)(3)
these tasks and to service rim wheels safely?
Does the facility have a restraining device on hand for inflating
30.5 3 29 CFR 1910.177(d)(1)
tires on multi-piece rims?
Has a safe operating procedure been developed for servicing 29 CFR 1910.177(f)
30.6 2
single and multi-piece rim wheels? and (g)
30.7 Other 1 N/A
Shipment or Receipt of Dangerous Goods
Have employees involved in shipping/receiving/ and/or packing

31.1 hazardous chemicals been properly trained including IATA 2 49 CFR and IATA
requirements?
For any packages that are received, do markings, labels and

31.2 placards remain on the container until the hazardous materials 2 29 CFR 1910.1201
are sufficiently removed to prevent potential hazards?
31.3 Other 1 N/A
Temp Workers
Do temporary employees (both ND and agency workers) receive

32.1 mandatory EHS training pertinent to the hazards in which they are 2 29 CFR 1910
exposed?
32.2 Other 1 N/A
Universal Waste
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Are universal wastes (e.g., batteries, lamps, mercury containing Universal Waste
33.1 equipment, pesticided) properly stored and labeled to identify the 2 Procedure
waste type and accumulation start date?
Universal Waste
33.2 Have personnel who handle universal wastes been trained? 2 Procedure
33.3 Other 1 N/A
Used Oil

Are containers and aboveground tanks storing used oil in good
34.1 condition (no severe rusting, apparent structural defects or 3 40 CFR 279.22(b)
deterioration) with no visible leaks?
Are containers and aboveground tanks storing used oil and fill
34.2 pipes used to transfer oil to USTs labeled or marked clearly with 3 40 CFR 279.22(c)
the words "Used Oil"?
34.3 Other 1 N/A
Working Alone
Are measures taken to provide employees with a communication
35.1 means or a check-in process for those who work alone in a 2 BMP
hazardous areas ?
35.2 Other 1 N/A
Young Workers
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36.1 Do young workers receive EHS training? 2 29 CFR 1910
36.2 Do young workers have oversight and do not work alone? 2 BMP
36.3 Other 1 N/A
Revised 8/15/2018 30 of 141

Aerial Lif
Observable Evidence
Interview users
Inspect fall protection equipment
Interview users
Review inspection forms.
Review training records.
<5 - all records

>5 - 75% of records
Interview personnel working on scaffolds to verify equipment is

inspected.
<5 - all records

>5 - 75% of records
N/A
Asbestos
Observable Evidence

<5 - all records
>5 - 75% of records
Interview affected employees
Verify warning signage is present
N/A
Revised 8/15/2018 31 of 141

Battery Charging
Observable Evidence
Observe battery charging area
Observe battery charging area
N/A
BBP & Sharps
Observable Evidence
Interview affected personnel.
Inspect area for sharps containers and verify they are appropriate.
Revised 8/15/2018 32 of 141


<5 - all records
>5 - 75% of records
Interview persons exposed to chemicals.
N/A
Chemical Exposure
Observable Evidence
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<5 - all records
>5 - 75% of records
Interview persons exposed to chemicals.
Review chemical containers for proper labeling.
Review documented inventory.
Review SDS library.

Randomly check chemicals and verify if SDS is available.
Revised 8/15/2018 34 of 141


<5 - all records
>5 - 75% of records
All affected employees must receive training for the extent of their job
function. The training shall include at a minimum: • All applicable
regulatory requirements for the hazards associated with the products
and chemicals that they have exposure. • Identification of physical and
health hazards of chemicals at facility • Handling and safe work practices
• Interpreting chemical inventory and SDS • Location of chemical
inventory and SDS • Explanation of site specific chemical labeling system

<5 - all records
>5 - 75% of records
Interview persons working on energized equipment.
Review the storage of flammable and combustible liquids.
The following quantities of liquid that may be located outside of an

inside storage room or storage cabinet in a building or in any one fire
area of a building:
(1) 25 gallons of Category 1 flammable liquids in containers
(2) 120 gallons of Category 2, 3, or 4 flammable liquids in containers
(3) 660 gallons of Category 2, 3, or 4 flammable liquids in a single
portable tank.
Interview employees performing non-routine tasks.
Revised 8/15/2018 35 of 141

Visual inspection : Oxidizers (nitrates, perchlorates, permanganates,

sulfuric, nitric and per chloric acids, etc.) and Flammables (acetone,
methanol, ethanol, ether)
- Water reactives and aqueous solutions
Observation
<5 - all records

>5 - 75% of records
N/A
Compressed Gas
Observable Evidence
Inspect compressed gas cylinders
N/A
Revised 8/15/2018 36 of 141

Cranes/Hoists
Observable Evidence
Are documented inspections conducted annually by qualified

personnel?
Inspection records
Visual of equipment
100% review documentation
Interview hoist/crane operators

<5 - all records
>5 - 75% of records
Verify load limit signage on hoist.
N/A
Observable Evidence
Revised 8/15/2018 37 of 141

Review completed CSE permits.

Interview personnel performing CSE activities.
Inspect each confined space to verify signage.

Review confined spaces operations for isolation to prevent unauthorized
entry.
Review training records of all personnel conducting CSE.

Review training records of affected personnel.
<5 - all records
>5 - 75% of records
Review confined spaces operations for isolation to prevent unauthorized
entry.
Review CSE permit or reclassification forms.
Review Contractor CS Information forms and CSE permits.
N/A
Combustible Dust
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Observable Evidence
Review housekeeping program

Interview personnel
Observe dust accumulations to verify less than a paper clip or dime thick
Review housekeeping program

Interview personnel

<5 - all records
>5 - 75% of records
N/A
Observable Evidence
Review written plan
Revised 8/15/2018 39 of 141

Interview personnel
Review training records
<5 - all records
>5 - 75% of records
Observation
Observation
Observation
Verify fire extinguishers are inspected and access is clear.
Interview personnel
Review training records
<5 - all records
>5 - 75% of records
Verify by review of chemicals and other materials used in area.
Verify safety showers are inspected and access is clear.
Verify safety eyewashes are inspected and access is clear.
N/A
Electrical
Observable Evidence
Revised 8/15/2018 40 of 141

Review area for extension cords.
Interview personnel using extension cords.
Review cabinets and boxes for unused openings.
Physical assessment of electrical equipment.
Physical assessment of extension cords.
Physical review of lighting.
Physical review of outlets.
Review receptacles for GFCI protection.
Physical review of equipment
Physical review of electrical rooms and MCC.
Physical review of electrical panels. Working space in front of the

electrical equipment must be minimum of 30 in. in width and 36 in. in
depth.
Revised 8/15/2018 41 of 141


<5 - all records
>5 - 75% of records
Interview persons working with live electrical conductors.
Review GFCI and interview personnel using portable power tools.
Review PPE for availability and condition.

Interview persons working on energized equipment.
Interview qualified personnel.
Review testing records
N/A
E-Waste
Observable Evidence
Observe work area

<5 - all records
>5 - 75% of records
Fall Protection
Observable Evidence
Inspect area to verify guarding.
Inspect stairs to verify handrails.
Revised 8/15/2018 42 of 141

Inspect elevated areas to verify signage.
Inspect area to verify guarding.
Interview personnel working at heights to ensure PFA systems being

utilized.
Inspect access point to roof to verify hazard assessment is posted and

signed by personnel.
Interview personnel accessing rooftop to verify they've been informed

of access procedures, or, that they are refraining from accessing if
hazard assessment is not posted.
Interview personnel working at heights to verify rescue plans are

developed.
<5 - all records

>5 - 75% of records
Interview personnel working at heights to verify equipment is inspected

and verify inventory is in place.
Inspect equipment.
Review records of periodic inspections by Competent Person.
Inspect PFA to verify that body belts are not present.
Interview personnel working at heights to verify body belts are not used.
Revised 8/15/2018 43 of 141

Interview personnel working at heights to verify equipment is inspected.
Inspect equipment.
N/A
FIFRA
Observable Evidence
Interview employees, review labeling
Interview employees
N/A
Guarding/Tools/Air
Observable Evidence
Review machinery for guarding. If this a machine shop a machine shop

audit should be conducted.
Observation
Observation
Review machinery for guarding. If this a machine shop a machine shop

audit should be conducted.
Revised 8/15/2018 44 of 141

Observation/interview
Safety guard covers the spindle end, nut, and flange projections.
Work rests kept adjusted to wheel with a maximum opening of 1/8 inch.
Tongue guard kept adjusted to wheel with a maximum opening of 1/4
inch.
Guards on right angle or vertical portable grinders are located between

the operator and the wheel.
Observation
Observation
Observe machine operators using equipment if possible.

Interview operators.
Review hand tools for condition and guarding.
Review air nozzles to verify they are set for 30 psi.
N/A
Hazardous Waste
Revised 8/15/2018 45 of 141

Observable Evidence
Review inspection records
Observe area
Observation

<5 - all records
>5 - 75% of records
Observe area. Interview employees.
Observe area. Interview employees.
N/A
Heat/Cold
Observable Evidence
<5 - all records
>5 - 75% of records
Interview personel
Revised 8/15/2018 46 of 141

N/A
Observable Evidence
Interview heavy mobile equipment operators and inspect equipment.
Interview heavy mobile equipment operators and inspect equipment.
Inspect mobile equipment.
Inspect mobile equipment.
Interview heavy mobile equipment operators and inspect equipment

cabs.
Review equipment where roll over potential exists and verify protective
structures are installed.

<5 - all records
>5 - 75% of records
Interview persons operating equipment.
N/A
Hot Work
Observable Evidence
Revised 8/15/2018 47 of 141

Review completed hot work permits.

Interview personnel performing hot work activities.


Inspect fire extinguishers, must be separate from building, wall
mounted. Ensure the fire extinguisher is in proper working condition and
within inspection dates.


Inspect PPE for availability and condition.

Revised 8/15/2018 48 of 141


Inspect gas cylinder storage and/or hot work equipment
Inspect welding equipment and area where used
Review training records for personnel involved in hot work activities.

<5 - all records
>5 - 75% of records
Inspect ALL hot work designated areas for housekeeping, welding

curtains, fire extinguishers, etc.
N/A
Housekeeping
Observable Evidence
Review areas
Interview young workers and supervisors
Review areas
N/A
Lif Trucks
Observable Evidence
Revised 8/15/2018 49 of 141

Review PIT battery charging areas. Are they designated and have
eyewash stations and spill absorbent if maintenance is performed?

<5 - all records
>5 - 75% of records

<5 - all records
>5 - 75% of records
Review inspection records.

<5 - all records
>5 - 75% of records
Review lift truck data plate.
N/A
LTT
Observable Evidence
Revised 8/15/2018 50 of 141

Review written energy control procedures. Interview personnel

performing lockout/tagout activities.
Review of equipment specific lockout inspection records. Interview

personnel performing lockout/tagout inspections.
Review training records of all personnel conducting lockout/tagout.
Review training records of affected personnel.

<5 - all records
>5 - 75% of records
Interview authorized employees to verify proper equipment is provided.
Revised 8/15/2018 51 of 141

Inspect authorized employees' issued equipment. Interview authorized

employees.
Inspect authorized employees' issued equipment.
Interview authorized employees to verify authorized personnel attempt

to restart equipment to verify effectiveness.
Interview authorized employees to verify procedures exist.
Review emergency lock removal records and interview personnel.
N/A
MMH
Observable Evidence
<5 - all records
>5 - 75% of records
N/A
Observable Evidence
Revised 8/15/2018 52 of 141


<5 - all records
>5 - 75% of records
Review inspection records
N/A
Noise
Observable Evidence
<5 - all records
>5 - 75% of records
Sound level survey of area
Interview employees
Observe hearing protection devices
Interview employees
Observation of work area for signage.
N/A
PPE
Observable Evidence
PPE hazard assessment
Revised 8/15/2018 53 of 141


<5 - all records
>5 - 75% of records
Interview personnel
Observe area
Interview personnel
Interview personnel
Interview personnel

<5 - all records
>5 - 75% of records
Review of 100% records.
N/A
Pressure Vessels
Observable Evidence
Revised 8/15/2018 54 of 141

Boiler inspection records
Interview personnel
Review records showing the deficiency and action
Inspect compressed air system

Interview personnel
Revised 8/15/2018 55 of 141

"Review training records.

<5 - all records
>5 - 75% of records
Interview affected employees"
N/A
Observable Evidence
Interview operators and RSO.

<5 - all records
>5 - 75% of records
Interview operators and RSO.

Review records
Review area for proper postings.
Locate the radiation safety manual.
N/A
Observable Evidence
Revised 8/15/2018 56 of 141

Interview laser operators and RSO.
Review area for proper signage.

<5 - all records
>5 - 75% of records
Eyewear must be available for inspection.
Interview laser operators.

Records must be on file in RMS.
Interview laser operators and RSO.
N/A
Service Tires
Observable Evidence
<5 - all records
>5 - 75% of records
Interview personnel
Revised 8/15/2018 57 of 141

Interview personnel
Interview personnel
Interview personnel and inspect equipment
Interview personnel and review procedure
N/A
pment or Receipt of Dangerous Goods
Observable Evidence
<5 - all records
>5 - 75% of records
Observe work area. Interview employees.
N/A
Temp Workers
Observable Evidence
<5 - all records
>5 - 75% of records
N/A
Universal Waste
Observable Evidence
Revised 8/15/2018 58 of 141

Observe work area

<5 - all records
>5 - 75% of records
N/A
Used Oil
Observable Evidence
Observe area
Observe area
N/A
Working Alone
Observable Evidence
Interview personnel
N/A
Young Workers
Observable Evidence
Revised 8/15/2018 59 of 141


<5 - all records
>5 - 75% of records
Interview young workers and supervisors
N/A
Revised 8/15/2018 60 of 141

Date: 30-Dec-99
Dear: 0
Department: 0
Building(s) / Location(s): 0
Thank you for participating in the Safety Assessment process. Attached is the report containing the assessment results for your department. Below you w
find a table summarizing the areas applicable to the department. As we reviewed your department, we asked questions and determined whether or not
question was met (Yes or No). Each question is weighted determining an overall score for your department.
At the end of our visit, we discussed time frames for corrective actions. If you feel more time is necessary to complete any of the recommended actions,
please email me within 7 business days the question number (far left column) and the revised target date.
As you complete items, please contact me so that we can schedule a follow up Validation inspection to verify closure. Once all items have been verifie
closed, the department will be validated.
If you have any questions or concerns please contact me at 631-5037 or at the email noted below.
Thank You,
0
0
Assessment Score #VALUE!
Revised 8/15/2018 61 of 141

Area Score Area Score Area

Sec 1 Aerial Lift N/A Sec 13 Fall Protection N/A Sec 25 Noise
Sec 2 Asbestos N/A Sec 14 FIFRA N/A Sec 26 PPE
Sec 3 Battery Charging N/A Sec 15 Guarding/Tools/Air N/A Sec 27 Pressure Vessels
Sec 4 Bloodborne Pathogens

and Sharps N/A Sec 16 Hazardous Waste N/A Sec 28 Radiation (Ionizing)
Sec 29 Radiation (Non-

Sec 5 Chemical Exposure N/A Sec 17 Heat/Cold N/A Ionizing)
Sec 18 Heavy Mobile

Sec 6 Compressed Gas N/A Equipment N/A Sec 30 Service Tires
Sec 31 Shipment or Receipt of

Sec 7 Cranes/Hoists N/A Sec 19 Hot Work N/A Dangerous Goods
Sec 8 Confined Space Entry N/A Sec 20 Housekeeping N/A Sec 32 Temporary Workers
Sec 9 Combustible Dust N/A Sec 21 Lift Trucks N/A Sec 33 Universal Waste
Sec 10 Emergency Action Plan N/A Sec 22 Lock, Tag, Try N/A Sec 34 Used Oil
Revised 8/15/2018 62 of 141

Sec 23 Manual Material

Sec 11 Electrical N/A Handling N/A Sec 35 Working Alone
Sec 12 E-Waste N/A Sec 24 Motor Vehicle Use/DOT N/A Sec 36 Young Workers
Repeat Findings
Revised 8/15/2018 63 of 141

ent results for your department. Below you will

ed questions and determined whether or not the
complete any of the recommended actions,
rify closure. Once all items have been verified as
Revised 8/15/2018 64 of 141

Score
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Revised 8/15/2018 65 of 141

N/A
N/A
Revised 8/15/2018 66 of 141

Revised 8/15/2018 67 of 141

Safety Assessment Chec
Date:
Assessm
Department:
Building(s) / Location(s):
#VA
Department Manager / Director:
Severity
Assistant Manager(s) / Director: Serious
(3)
Division Safety Committee Chair:
Division Vice President: 0
RMS Staff Conducting Audit:

RMS Staff Contact:
Section 1
Aerial Lif
Repeat
Q# Question Yes/No/NA Findings Severity
(Y/N/NA)
Revised 8/15/2018 68 of 141

Is fall arrest equipment worn by persons

1.1 working from aerial lifts and other similar N/A N/A N/A
mobile equipment used to elevate workers?
Are pre-use equipment inspections and

1.2 workplace inspections conducted and N/A N/A N/A
documented when using aerial and scissor lifts?
Are personnel trained prior to operating an

1.3 N/A N/A N/A
aerial or scissor lift?
Are scaffolds inspected by a competent person
1.4 N/A N/A N/A
before use?
1.5 Are personnel who work on scaffolds trained? N/A N/A N/A
1.6 Other N/A N/A N/A
Section 2
Asbestos
Repeat
(Y/N/NA)
Have all affected employees who may in the

2.1 course of employment contact ACMs and N/A N/A N/A
PACMs completed asbestos awareness training?
2.2 Are areas containing ACMs properly labeled? N/A N/A N/A
Section 3
Battery Charging
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Repeat
(Y/N/NA)
Do truck battery charging areas at the site meet

the following requirements?
• Areas are designed and properly equipped;
• Charging equipment is protected from being

3.1 N/A N/A N/A
struck by trucks; and
• Workers are required to wear goggles, face

shield, and chemically-resistant aprons and
gloves when adding water or acid to wet cell
batteries.
Are precautions taken to prevent open flames,

3.2 sparks, or electric arcs in battery charging N/A N/A N/A
areas?

Section 4
BBP & Sharps
Repeat
(Y/N/NA)
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Is it prohibited to eat, drink, smoke, apply

cosmetics, and handle contact lenses in work
4.1 N/A N/A N/A
areas where the potential exists for exposure to
blood borne pathogens?
Are containers used for sharps disposal easily

accessible and located in the area where sharps
are used or can be reasonably anticipated to be
4.2 N/A N/A N/A
found?
Are full containers disposed by RMS?
Is contaminated laundry handled as little as

possible with a minimum movement?
Is contaminated laundry placed and transported

in bags or containers labeled with the biohazard
symbol or colored red?
4.3 N/A N/A N/A
Is wet contaminated laundry placed and
transported in bags or containers that will
prevent soak-through and/or leakage of fluids
to the exterior?
Is PPE used when handling contaminated

laundry?
Within 10 days of initial assignment, is the

hepatitis B vaccination series made available to
4.4 persons whose job is reasonably anticipated to N/A N/A N/A
have contact with blood or other potentially
infectious materials
Revised 8/15/2018 71 of 141

Have persons who refused to take the hepatitis
B vaccination series signed a statement to that
4.5 N/A N/A N/A
effect following the form prescribed by the
OSHA standard?
Are individuals who are reasonably anticipated

to have contact with blood or other potentially
infectious materials in the course of their work
or student activities provided training on blood
borne pathogens?
Is blood borne pathogen training provided

4.6 before or at the time of initial assignment N/A N/A N/A
where contact with blood or other potentially
infectious materials is possible?
Is the blood borne pathogen training material

appropriate in content and vocabulary to the
educational level, literacy, and language of
people to be trained?
Section 5
Chemical Exposure
Repeat
(Y/N/NA)
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Have personnel received training on their right

5.1 of access to relevant exposure and medical N/A N/A N/A
records?
Are containers of hazardous chemicals is

labeled, tagged or marked with the appropriate
information?
Each container of hazardous chemicals is

labeled with the following information: (i)
identity of the hazardous chemical; and, (ii)
appropriate hazard warnings, or alternatively,
5.2 words, pictures, symbols, or combination N/A N/A N/A
thereof, which provide at least general
information regarding the hazards of the
chemicals, and which, in conjunction with the
other information immediately available to
employees under the hazard communication
program, will provide employees with the
specific information regarding the physical and
health hazards of the hazardous chemical.
Is a documented inventory of all chemicals

5.3 N/A N/A N/A
taken annually?
Are safety data sheets (SDS) available for each
5.4 N/A N/A N/A
used in the workplace?
Are employees provided hazard communication
5.5 N/A N/A N/A
training?
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Are personnel trained on hazardous chemicals

in their work area at the time of their initial
5.6 assignment, and whenever a new chemical N/A N/A N/A
hazard the employees have not previously been
trained about is introduced into their work
area?
Are flammable or combustible liquids stored in

proper containers? The containers must comply
with the applicable design, construction and
5.7 capacity requirements. All containers of N/A N/A N/A
flammable or combustible liquids are stored in
storage cabinets or in properly designed and
constructed inside storage rooms.
Have methods been developed to inform

5.8 N/A N/A N/A
employees of the hazards of non-routine tasks?
Are incompatable chemicals/wastes segregated

5.9 N/A N/A N/A
properly?
Is dry ice stored in a well ventilated location (no

walk-in freezers or coolers) and placed in a
container designed for the storage of dry ice
5.10 N/A
and dry ice baths open to the atmosphere? Is
unneeded dry ice properly disposed (never
placed in sink, toilet, drain, or trash can)?
Have personnel who ship packages containing

5.11 dry ice been trained on DOT/IATA N/A
requirements?
Revised 8/15/2018 74 of 141

Section 6
Compressed Gas
Repeat
(Y/N/NA)
Do compressed gas cylinders meet the
6.1 following requirements (as applicable)? N/A N/A N/A
6.2 •Other
Cylinders are secured at all times to prevent N/A N/A N/A
tipping, falling, or rolling;
• Safety caps replaced when not in use Section 7
• Cylinders are only transported using carts or
other devices specifically designed for moving Cranes/Hoists
cylinders;
• Cylinder contents must be clearly labeled; Repeat
Q# • Cylinders are keptQuestion
shaded from direct Yes/No/NA Findings Severity
(Y/N/NA)
sunlight;
• Oxygen cylinders are separated from fuel-gas
cylinders;
Are visual inspections
• Cylinders and functional
and components are kept checks
free from
7.1 conducted prior
oil and grease; to usage? Are these N/A N/A N/A
documented
• Cylinders areonequipped
an inspection
with sheet?
pressure relief
valves;
Are documented inspections conducted of
cranes, hoists, ropes, chains, slings by by
7.2 qualified personnel (e.g., outside vendor), N/A N/A N/A
including initial load testing?
Are all under-hook lifting attachments in safe

working order, properly stored, and thorough
7.3 inspection conduction at least once every 12 N/A N/A N/A
months?
Are personnel informed that loads shall not be

7.4 moved over people and tag lines shall be used N/A N/A N/A
on loads that must be guided in to position?
Revised 8/15/2018 75 of 141

Are crane, hoist operators and maintenance

personnel properly trained in safe operating
7.5 procedures and equipment inspections N/A N/A N/A
requirements?
Is the rate load of the crane plainly marked on

7.6 each side and is the marking clearly legible from N/A N/A N/A
the ground or floor?
Section 8
Repeat
(Y/N/NA)
Before entry operations begin, has a permit

been properly completed?
8.1 Has the permit been cancelled at the end of the N/A N/A N/A
CSE?
Are permits retained for recordkeeping?
Are signs posted at the CS that inform

8.2 N/A N/A N/A
employees of permit spaces?
Revised 8/15/2018 76 of 141

Has the space been tested to determine if

8.3 N/A N/A N/A
acceptable enter conditions exist prior to entry?
Are attendants assigned and stationed outside

8.4 the confined space for the duration of the entry N/A N/A N/A
operation?
Is the confined space sufficiently isolated to
8.5 N/A N/A N/A
prevent unauthorized entry?
Have the entrants been provided the
8.6 opportunity to observe any monitoring or N/A N/A N/A
testing of atmospheres?
Are competent persons, attendants, and
8.7 N/A N/A N/A
entrants trained?
Are affected employees trained in the CS
8.8 N/A N/A N/A
hazards and program?
Is there a system for summoning rescue and
8.9 N/A N/A N/A
emergency services?
If confined space has been reclassified to a non-

8.10 permitted space is there documentation that all N/A N/A N/A
the hazards have been eliminated?
When contractors are performing CS Entry, are

documented Contractor Confined Space
8.11 N/A N/A N/A
information forms retained on file as well as
completed entry permits?
Revised 8/15/2018 77 of 141

Section 9
Combustible Dust
Repeat
(Y/N/NA)
Is there a housekeeping program to manage the
9.1 dust accumulations to less than 1/32nd of an N/A N/A N/A
inch (i.e. the thickness of a paper clip)?
Are the cleaning methods NOT dry methods

9.2 such as using brushes or compressed air that N/A N/A N/A
can disperse dust in the area?
Are personnel trained of the combustible
9.3 N/A N/A N/A
nature of the dust?
Section 10
Repeat
(Y/N/NA)
Revised 8/15/2018 78 of 141

Is a written emergency action plan available

that includes the following items?
a. Emergency escape procedures, signals, and
routes
b. Procedures for designated employees who
must remain in the facility to shut down
equipment before they evacuate
10.1 c. Procedures to account for all building N/A N/A N/A
occupants
d. Rescue and medical duties
e. Preferred mechanisms for building occupants
to report emergencies
f. Names and job titles of people who can be
contacted for more information regarding
evacuation plans
Is the emergency action plan made available to

building occupants and have all employees
been trained on the plan? Have designated
10.2 N/A N/A N/A
employees assigned to help with the safe and
orderly evacuation of all building occupants
been properly trained?
Are exits signs clearly visible and illuminated

10.3 N/A N/A N/A
and are exits clear and unobstructed?
Are doors, passageways or stairways that are

neither exits nor a way to an exit, and which can
10.4 N/A N/A N/A
be mistaken for an exit, marked with a sign
reading "Not An Exit" or similar designation?
Is the vertical clearance between sprinklers and

10.5 material below at least 18 inches? N/A N/A N/A
Revised 8/15/2018 79 of 141

Is the fire extinguisher mounted and inspected

monthly? Is access to the fire extinguisher
10.6 N/A N/A N/A
unobstructed? Is fire extinguisher within the
annual inspection date.
Are personnel trained annually on fire

10.7 extinguisher use? N/A N/A N/A
Are suitable facilities for quick drenching or

flushing of the eyes and body available in work
10.8 N/A N/A N/A
areas where the eyes or body may be exposed
to corrosive materials?
Is there unobstructed access to the safety

10.9 shower, and annual inspection by facilities is N/A N/A N/A
documented?
Is there unobstructed access to the eyewash
10.10 station and inspected monthly? N/A N/A N/A
Section 11
Electrical
Repeat
(Y/N/NA)
Revised 8/15/2018 80 of 141

Where in use, are extension cords in safe

working condition and used properly for no
longer than 90 days?
11.1 N/A N/A N/A
Must not be: (a) attached to building surfaces;
(b) concealed; (c) run through holes in walls,
ceilings, or floors; or (d) run through doorways,
windows, or similar openings
Are all unused openings in cabinets, junction

11.2 N/A N/A N/A
boxes, and fittings effectively closed?
Are all disconnecting switches, electric boxes,

cabinets, circuit breaker panels, etc., labeled to
11.3 N/A N/A N/A
indicated their use, voltage, or equipment
served?
Are extension cords or power strips NOT

plugged into one another (daisy chained) and
11.4 N/A N/A N/A
not used to power appliances (e.g., microwave
ovens, refrigerators)?
Where lights are used for general illumination,

11.5 are they protected from accidental contact by a N/A N/A N/A
fixture or guard and without damage?
Are receptacles or switches in good condition?

11.6 N/A N/A N/A
Are electrical pendant drops properly designed?
Are receptacles on rooftops, in outdoor areas,

11.7 N/A N/A N/A
or near water sources GFCI protected?
Is electric equipment operating at 50 volts or

11.8 N/A N/A N/A
more guarded?
Revised 8/15/2018 81 of 141

Are electrical rooms free from being used for

11.9 N/A N/A N/A
storage?
11.10 Are electrical panels unobstructed (clear area at N/A N/A N/A
least 30" wide x 36" deep)?
Are only qualified persons permitted to work on

11.11' energized electric circuit parts (>50 volts) or N/A N/A N/A
equipment that has not been deenergized?
Are employees provided ground fault circuit

11.12 interrupter (GFCI) protection while using N/A N/A N/A
powered equipment?
Are employees who work in areas where

11.13 electrical hazards exist provided with and N/A N/A N/A
required to use PPE?
Are insulating equipment (gloves, mats, etc.)

11.14 inspected before each day’s use and electrically N/A N/A N/A
tested every 6 months for gloves?
Section 12
E-Waste
Repeat
(Y/N/NA)
Are e-wastes properly labeled or marked to
12.1 N/A N/A N/A
identify "Electronic Waste"?
Have personnel who handle e- wastes been
12.2 N/A N/A N/A
trained?
Revised 8/15/2018 82 of 141

Section 13
Fall Protection
Repeat
(Y/N/NA)
Is every open-sided platform 4 feet or more,

13.1 N/A N/A N/A
guarded by a standard railing and toe board?
Are stairs with four or more risers, equipped

13.2 with standard stair railings or standard N/A N/A N/A
handrails?
Are load limits posted on elevated floors,

13.3 N/A N/A N/A
mezzanines, and other elevated storage areas?
Do covers protect employees on a walking and

13.4 working surface from tripping in or stepping N/A N/A N/A
into holes (including skylights)?
Do guardrail systems or personal fall arrest

systems protect employees when they work on
13.5 N/A N/A N/A
unprotected sides and edges of walking and
working surfaces or into dangerous equipment?
Have all employees who access rooftop areas

been informed of required access procedures
and signed and dated the posted hazard
13.6 assessment? If a hazard assessment is not N/A N/A N/A
posted, do employees refrain from accessing
the roof?
Revised 8/15/2018 83 of 141

Are provisions made for prompt rescue in the

13.7 event of a fall, or are employees able to rescue N/A N/A N/A
themselves?
Have all employees who use fall protection
13.8 N/A N/A N/A
completed fall protection training?
Is there a documented inventory of Personal

Fall Arrest Systems? Are Personal Fall Arrest
Systems inspected before each use and
13.9 N/A N/A N/A
periodically by a Competent Person and
documented? Are defective parts removed from
service? Is the use of body belts prohibited?
13.10' Are portable ladders inspected before use? N/A N/A N/A
Section 14
FIFRA
Repeat
(Y/N/NA)
Does the facility use registered pesticides in a
14.1 manner consistent with the pesticide's labeling? N/A N/A N/A
Do personnel who use restricted use pesticides

14.2 apply under the direct supervision of a certified N/A N/A N/A
applicator?
Section 15
Guarding/Tools/Air
Repeat
(Y/N/NA)
Revised 8/15/2018 84 of 141

Are all machines guarded to protect the

operator and other people in the machine area
15.1 from hazards such as those created by point of N/A N/A N/A
operation, ingoing nip points, rotating parts,
flying chips, and sparks?
Are shaft ends that project more than 1/2 of the

15.2 diameter of the shaft protected by nonrotating N/A N/A N/A
caps or safety sleeves?
Are guards firmly secured, not easily removable

15.3 N/A N/A N/A
and free from burrs and sharp edges?
Is all machinery designed for a fixed location

15.4 securely anchored to prevent its "walking" or N/A N/A N/A
"moving"?
Are all machines requiring the presence of an
15.5 operator not left unnattended while in N/A N/A N/A
operation of still in motion?
Are abrasive wheel tools equipped with proper

guards, guard properly adjusted, and the wheel
15.6 N/A N/A N/A
free of damage and ring tested prior to
mounting?
Are all machine controls clearly marked to

indicate their intended operation? Are
15.7 machines that are equipped with emergency N/A N/A N/A
stop buttons have the e-stops located in close
proximity to the operator and red in color?
Are all fans less than 7 feet from the floor

15.8 equipped with guards that have openings no N/A N/A N/A
larger than one half (1/2) inch?
Revised 8/15/2018 85 of 141

Are those who operate machines wearing the

appropriate PPE and have no loose fitting
15.9 N/A N/A N/A
clothing, hair or jewelry that could become
entangled?
Are hand and portable power tools are in good

condition and properly guarded, including tools
15.10 N/A N/A N/A
and equipment which may be furnished by
employees.
Is it prohibited to use compressed air for

cleaning purposes except when it is reduced to
15.11 less than 30 psi and then only with effective N/A N/A N/A
chip guarding and personal protective
equipment?
Section 16
Hazardous Waste
Repeat
(Y/N/NA)
Are periodic inspections of satellite storage
16.1 N/A N/A N/A
areas being conducted and documented?
Are containers clearly labeled with the words

"hazardous waste" with each constituent noted
16.2 on the label, in good condition (leak proof and N/A N/A N/A
clean) and kept securely closed when not in
use?
Are wastes stored in containers that have

secondary containment large enough to contain
16.3 10% of the volume of the total container or N/A N/A N/A
100% of the volume of the largest container,
whichever is greater?
Revised 8/15/2018 86 of 141

Have personnel who handle hazardous wastes

16.4 N/A N/A N/A
been trained?
Is the quantity of waste less than 55 gallons or

16.5 N/A N/A N/A
less than 1 quart for accutely toxic waste?
Are contaminated rags/wipes saturated with

solvents properly stored in an approved metal
16.6 N/A
can with a tight fitting lid and properly
labeled :Hazardous Waste Contaminated Rags"?
Section 17
Heat/Cold
Repeat
(Y/N/NA)
Are personnel trained in heat and cold stress
17.1 hazards and methods to take to prevent injury N/A N/A N/A
or illness?
Are personnel provided fluids and/or

administrative controls, e.g., job rotation or
17.2 N/A N/A N/A
more frequent breaks to alleviate the extreme
temperatures?
Section 18
Repeat
(Y/N/NA)
Does equipment in which the operator cannot
directly or by mirror or other effective device
18.1 N/A N/A N/A
see immediately behind the machine have an
automatic audible warning device?
Revised 8/15/2018 87 of 141

Does equipment used at night have and use

18.2 lights to adequately illuminate the direction of N/A N/A N/A
travel, working area immediately around the
equipment and cab instruments?
18.3 Are operating controls identified to show the N/A N/A N/A
function they serve?
Are windshields, side and rear windows, and
rear-vision mirrors maintained to provide clear
18.4 vision to the operator for the safe operation of N/A N/A N/A
the equipment?
If work is being performed and elevated over

18.5 the cab, is the cab protected by an adequate N/A N/A N/A
overhead guard?
Are Rollover Protective Structures (ROPS)
18.6 installed on any mobile equipment where the N/A N/A N/A
possibility of a rollover exists?
Have all authorized drivers been properly
18.7 trained on each piece of equipment they are N/A N/A N/A
permitted to operate?
Section 19
Hot Work
Repeat
(Y/N/NA)
Are Hot Work Permits obtained for hot work
19.1 N/A N/A N/A
activities in non-designated hot work areas?
Revised 8/15/2018 88 of 141

Is the equipment being worked on thoroughly

cleaned / purged of flammable or combustible
materials?
19.2 N/A N/A N/A
Are all movable fire hazards removed (>35') and
all non-movable objects and adjacent
employees protected by barriers, including
outdoor areas?
Is suitable fire extinguishing equipment

maintained in a state of constant readiness and
used by fire watchers?
19.3 N/A N/A N/A
Building fire extinguishers shall not be used for
fire watch.
Are firewatchers required and used during hot

19.4 N/A N/A N/A
work activities?
Is the fire watch maintained for at least 30

19.5 N/A N/A N/A
minutes after completion of the hot work?
Is PPE provided to individuals performing the

hot work activity?
19.6 N/A N/A N/A
Do welding or cutting goggles, helmets and face
shields employ the correct filtered lens (shade
number) for the welding operation?
Revised 8/15/2018 89 of 141

Are gas cylinders properly labeled, transported

and separated (empties from non-empties),
associated piping properly secured, and safety
caps replaced when not in use?
19.7 N/A N/A N/A
Are welding hoses, leads, or cables free of
damage and kept clear of passageways, ladders,
and stairways?
Have employees involved in Hot Work tasks

(persons performing work, Fire Watches, etc.)
trained in Hot Work Employee Training, Hot
19.8 Work Fire Watch and Hot Work Permit Issuer N/A N/A N/A
training ?
Is the designated hot work area (permit not

required) maintained with proper
housekeeping?
19.9 N/A N/A N/A
Combustibles kept 35' away, fire extinguishing
equipment present and maintained, signage
posted?
19.10' Other N/A N/A N/A
Section 20
Housekeeping
Repeat
(Y/N/NA)
Are storage areas kept free from accumulation
20.1 of materials that constitute hazards from N/A N/A N/A
tripping, fire, explosion, or pest harborage?
Revised 8/15/2018 90 of 141

Are aisles and passageways kept clear and in

20.2 good repairs, with no obstructions across or in N/A N/A N/A
aisles that could create a hazard?
Are all areas, passageways, storerooms, and
20.3 service rooms kept clean and orderly and in a N/A N/A N/A
sanitary condition?
Section 21
Lif Trucks
Repeat
(Y/N/NA)
Are battery charging installations located in
areas designated for that purpose? If
maintenance is performed on batteries, are
21.1 facilities provided for flushing and neutralizing N/A N/A N/A
spilled electrolyte?
Have lift truck and/or powered pallet operaters

21.2 completed training? N/A N/A N/A
Are evaluations performed of each powered
21.3 industrial truck operator's performance at least N/A N/A N/A
once every three years?
Are the fork trucks inspected prior to use each

21.4 N/A N/A N/A
shift and inspections properly documented?
If lift truck attachments are used (e.g. container

handlers, carton clamps, barrel clamps, etc)
have operators been trained on its operation
21.5 and limitations and has the trucks data plate N/A N/A N/A
been updated to include details of attachment?
Revised 8/15/2018 91 of 141

Section 22
LTT
Q# Question Yes/No/NA Findings Repeat Severity
(Y/N/NA)
Are equipment-specific energy control

procedures available for each piece of
equipment that address the elements listed
below?
• Identification of the equipment and/or task

• Type and magnitude of all hazardous energy
sources
• Listing of all applicable energy isolation
22.1 devices N/A N/A N/A
• Specific steps to obtain zero energy state
• Specific steps for verifying energy control
including the release of stored energy
Written procedures are NOT required for cord

and plug connected equipment and pieces of
equipment that have single, readily identifiable
energy isolation devices if there is no potential
for stored energy after shut down.
Are periodic audits conducted to ensure

authorized persons are following prescribed
22.2 energy control procedures and that energy N/A N/A N/A
controls are being utilized properly?
22.3 Have authorized persons been trained? N/A N/A N/A
Revised 8/15/2018 92 of 141

Have affected employees been trained in the

22.4 purpose and use of the energy control N/A N/A N/A
procedure.
Are locks, tags, or other hardware provided for

isolating, securing and blocking of machines or
22.5 N/A N/A N/A
equipment from energy sources?
Are lockout and tagout devices red in color for

personal locks, blue for group lockout, and
green for long term isolation? Are locks
prohibited from use for other purposes, capable
22.6 of withstanding the environment to which they N/A N/A N/A
are exposed, standardized, i.e. color, shape,
size, paint and format, and substantial enough
to prevent removal without the use of excessive
force?
Are locks equipped with tags that read “Do not

start”, “Do not open”, “Do not close”, “Do not
22.7 N/A N/A N/A
energize”, or ‘Do not operate” and identify the
lock owner?
Do authorized persons verify that de-energizing

has been effective by attempting to start the
22.8 N/A N/A N/A
equipment and release residual energy before
starting servicing or maintenance work?
Do procedures exist for removing and

transferring locks and tags? Are documented
22.9 N/A N/A N/A
emergency lcok removal forms completed in
such situations?
22.10' Other N/A N/A N/A
Revised 8/15/2018 93 of 141

Section 23
MMH
Repeat
(Y/N/NA)
Is proper lifting training provided for personnel

23.1 N/A N/A N/A
who routinely lift >35 lbs.
Section 24
(Y/N/NA)
Have employees who operate motor vehicles
24.1 transporting hazardous materials been properly N/A N/A N/A
trained?
24.2 Are vehicles inspected prior to use? N/A N/A N/A
Section 25
Noise
Repeat
(Y/N/NA)
Is annual Hearing Conservation training
25.1 N/A N/A N/A
provided to all employees in the HCP?
Have all operations or equipment believed to
25.2 exceed 85 dBA TWA been measured to N/A N/A N/A
determine noise levels?
Is hearing protection provided and required for
25.3 employees in the hearing conservation N/A N/A N/A
program?
Revised 8/15/2018 94 of 141

Do personnel who are in the hearing

25.4 conservation program complete annual N/A N/A N/A
audiograms?
For areas exceeding 85 dBA are they properly
25.5 labeled and identified as areas requiring N/A N/A N/A
hearing protection?
Section 26
PPE
Repeat
(Y/N/NA)
26.1 Has a PPE hazard assessment been completed? N/A N/A N/A
Is training provided to each employee that is

26.2 N/A N/A N/A
required to use PPE?
26.3 Is the PPE provided at no cost to employees? N/A N/A N/A
Are suitable eye protection (ANSI Standard

Z87.1) required where operations present the
26.4 N/A N/A N/A
hazard of flying particles, liquid chemicals, acids
or caustic liquids, chemicals, etc.?
Are employees required to wear an approved

protective hard hat (ANSI Z89.1) when working
26.5 N/A N/A N/A
in areas where there is a potential for injury to
the head from falling objects?
Revised 8/15/2018 95 of 141

Are employees required to use protective

footwear, (ANSI Z41) when working in areas
26.6 where there is a danger of foot injuries due to N/A N/A N/A
falling or rolling objects, or objects piercing the
sole, and where employee’s feet are exposed to
electrical hazards?
Are employees required to use appropriate

hand protection when hands are exposed to
such hazards as those from skin absorption of
26.7 harmful substances, severe cuts or lacerations, N/A N/A N/A
severe abrasions, punctures, chemical burns,
thermal burns, and harmful temperature
extremes?
26.8 Are respirator users trained? N/A N/A N/A

For employees who voluntarily wear a
26.9 respirator, have they completed a Voluntary Use N/A N/A N/A
Form?

Section 27
Pressure Vessels
Repeat
(Y/N/NA)
Are boilers and pressure vessels inspected by
competent persons and listed on the inventory
27.1 maintained by Facilities, Design and Operations N/A N/A N/A
division?
If a deficiency is noted during an inspection, is

the equipment labeled as "Do Not Use" and
27.2 N/A N/A N/A
taken out of service until the deficiency is
corrected through corrective action?
Revised 8/15/2018 96 of 141

Do compressed air systems at the site meet

following requirements (as applicable)?
• Air receiver tanks are equipped with a pressure

gauge, relief valve of adequate capacity, and a drain
at the lowest level to allow for removal of
accumulated oil and water.
• Air compressors are not used to generate
breathing air for supplied air respirators without the
written permission from RMS.
• Flammable liquids such as solvents are not stored
or used within 35 feet of an air compressor.
• Compressed air is not used to clean clothing or
body parts.
• Air nozzles used for compressed air cleaning is
specifically designed to reduce air consumption and
minimize excessive noise levels. Nozzles are able to
reduce air pressure to less than 30 psi (2 bar) if the
27.3 nozzle tip is blocked. N/A N/A N/A
• Worm gear clamps or radiator-style clamps are not
used to secure hose fittings to compressed air
hoses. Ear clamps, crimp sleeves, ferrules, or press-
on fittings rated for the maximum allowable working
pressure are used.
• Compressed air hose couplings used for cleaning
nozzles or compressed air tools are equipped with
locking sleeves to prevent accidental disconnection.
Revised 8/15/2018 97 of 141

Is Pressure Vessel/Systems Safety training

provided for employees who operate air
compressors that includes the following topics?
27.4 N/A N/A N/A
• Start-up and shutdown procedures
• System parameters and actions to take when
performance varies from those parameters
• Inspection requirements
Section 28
Repeat
(Y/N/NA)
Has the use of radiation in this area been
28.1 approved by the campus Radiation Control N/A N/A N/A
Committee?
Is there documentation that all personnel
working in the area where the radioactive
28.2 materials are used and/or stored have been N/A N/A N/A
appropriately trained?
Are the records for radioactive material use,

28.3 contamination surveys, and inventory properly N/A N/A N/A
updated and maintained for inspection?
Is the NRC Form 3 "Notice to Employees"

posted. In areas using machine produced
28.4 N/A N/A N/A
radiation (x-ray machines) is ISDH Board Form X
on or near the unit or its control panel.
Revised 8/15/2018 98 of 141

Is the Radiation Safety Manual available in the

28.5 room and have personnel been informed of its N/A N/A N/A
location?
Section 29
Repeat
(Y/N/NA)
Have all lasers and laser areas been approved
29.1 by the campus Laser Safety Officer? N/A N/A N/A
Are laser use areas identified by the proper

29.2 signage, including lighted signs for Class 4 N/A N/A N/A
lasers?
Is there documentation of Laser Safety training?
29.3 N/A N/A N/A
Is the appropriate Laser Safety Eyewear
29.4 available? N/A N/A N/A
Have all laser users undergone a baseline eye
29.5 exam as required by the Laser Safety Manual? N/A N/A N/A
Is the Laser Safety Manual available in the room

29.6 and have personnel been informed of its N/A N/A N/A
location?
Section 30
Service Tires
(Y/N/NA)
Revised 8/15/2018 99 of 141

Is there a program to train all employees who

service rim wheels in the hazards involved in
30.1 N/A N/A N/A
servicing those rim wheels, and the safety
procedures to be followed?
Does the employer ensure that no employee
services any rim wheel unless the employee has
been trained and instructed in correct
procedures of servicing the type of wheel being
30.2 serviced and in the safe operating procedures N/A N/A N/A
described in paragraphs (f) and (g) of 29 CFR
1910.177?
Does the employer ensure that each employee

30.3 demonstrates the ability to service rim tires N/A N/A N/A
safely?
Does the employer evaluate each employees'
30.4 ability to perform these tasks and to service rim N/A N/A N/A
wheels safely?
Does the facility have a restraining device on

30.5 N/A N/A N/A
hand for inflating tires on multi-piece rims?
Has a safe operating procedure been developed

30.6 for servicing single and multi-piece rim wheels? N/A N/A N/A
Section 31
Shipment or Receipt of Dangerous Goods
(Y/N/NA)
Revised 8/15/2018 100 of 141

Have employees involved in shipping/receiving/

31.1 and/or packing hazardous chemicals been N/A N/A N/A
properly trained including IATA requirements?
For any packages that are received, do

markings, labels and placards remain on the
container until the hazardous materials are
31.2 sufficiently removed to prevent potential N/A N/A N/A
hazards?
Section 32
Temp Workers
Repeat
(Y/N/NA)
Do temporary employees (both ND and agency
workers) receive mandatory EHS training
32.1 N/A N/A N/A
pertinent to the hazards in which they are
exposed?
Section 33
Universal Waste
Repeat
(Y/N/NA)
Are universal wastes (e.g. batteries, lamps,
mercury containing equipment, pesticided)
33.1 N/A N/A N/A
properly stored and labeled to identify the
waste type and accumulation start date?
Have personnel who handle universal wastes
33.2 N/A N/A N/A
been trained?
Section 34
Used Oil
Revised 8/15/2018 101 of 141

Repeat
(Y/N/NA)
Are containers and aboveground tanks storing

used oil in good condition (no severe rusting,
34.1 apparent structural defects or deterioration) N/A N/A N/A
with no visible leaks?
Are containers and aboveground tanks storing

used oil and fill pipes used to transfer oil to
34.2 USTs labeled or marked clearly with the words N/A N/A N/A
"Used Oil"?
Section 35
Working Alone
Repeat
(Y/N/NA)
Are measures taken to provide employees with

a communication means or a check-in process
35.1 N/A N/A N/A
for those who work alone in a hazardous
areas ?
Section 36
Young Workers
Revised 8/15/2018 102 of 141


(Y/N/NA)
36.1 Do young workers receive EHS training? N/A N/A N/A

Do young workers have oversight and do not
36.2 work alone? N/A N/A N/A
Revised 8/15/2018 103 of 141

Assessment Score Total Repeats
#VALUE! 0
Finding Severity
Severity Severity
Moderate Minor
(2) (1)
0 0
Section 1
Aerial Lif
Action Target Date Status Score
Revised 8/15/2018 104 of 141

Percent
N/A
Section 2
Asbestos
Percent
N/A
Section 3
Battery Charging
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Percent
N/A
Section 4
BBP & Sharps
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Percent
N/A
Revised 8/15/2018 107 of 141

n5
xposure
Action Target Date Status
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Score
Percent
N/A
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Score
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n6
ed Gas Percent

N/A
Score
n7
oists Percent
N/A
Revised 8/15/2018 111 of 141

Score
n8
ace Entry Percent
N/A
Revised 8/15/2018 112 of 141

Score
Percent
Revised 8/15/2018 113 of 141

n9
le Dust N/A
Score
Percent
10
ction Plan N/A
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Revised 8/15/2018 115 of 141

11 Score
cal
Percent
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N/A
Revised 8/15/2018 117 of 141

12 Score
te
Action Target Date Status Percent
N/A
Revised 8/15/2018 118 of 141

13
ction
Percent
N/A
Revised 8/15/2018 119 of 141

Section 14
FIFRA
Percent
N/A
Section 15
Guarding/Tools/Air
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Percent
N/A
Score
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Percent
N/A
16
Waste
Score
Percent
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N/A
Score
17
old Percent
Action Target Date Status N/A
18
Equipment
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Score
Percent
N/A
19
ork
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Score
Percent
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N/A
20 Score
eping
N/A
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21
cks
Percent
N/A
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22
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Score
Percent
N/A
Score
Percent
N/A
Revised 8/15/2018 129 of 141

23
H
Score
Percent
24
Use/DOT N/A
25 Score
e
N/A
Revised 8/15/2018 130 of 141

26
Score
Percent
N/A
Revised 8/15/2018 131 of 141

27
essels
Score
Percent
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N/A
Revised 8/15/2018 133 of 141

28
onizing)
Score
Percent
N/A
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29
n-Ionizing)
Score
Percent
N/A
30
Tires
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Score
Percent
N/A
31 Score
Dangerous Goods
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N/A
Score
32
rkers Percent
Action Target Date Status N/A
33
Waste
Percent
N/A
34
Oil
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Percent
N/A
35 Score
Alone
Percent
N/A
36
orkers
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Revised 8/15/2018 139 of 141

APPENDIX C
Definitions:
Flammable Liquid. Any liquid that has a closed-cup

flash point below 100°F (37.8°C), and a Reid vapor pressure that does not
exceed an absolute pressure of 40 psi (276 kPa) at 100°F (37.8°C)
Class IA Liquid —Any liquid that has a flash point below 73°F (22.8°C) and a
boiling point below 100°F (37.8°C)
Class IC Liquid — Any liquid that has a flash point at or above 73°F (22.8°C),
but below 100°F (37.8°C)
Class IB Liquid —Any liquid that has a flash point below 73°F (22.8°C) and a
boiling point at or above 100°F (37.8°C)
Combustible Liquid. Any liquid that has a closed-cup flash point at or above
100°F (37.8°C)
Combustible liquids shall be classified in accordance with the following:

(1) Class II Liquid — Any liquid that has a flash point at or above 100°F (37.8°C)
and below 140°F (60°C)
(2) Class III Liquid — Any liquid that has a flash point at or above 140°F (60°C)
(a) Class IIIA Liquid—Any liquid that has a flash point at or above 140°F (60°C),
but below 200°F (93°C)
(b) Class IIIB — Any liquid that has a flash point at or
above 200°F (93°C)
Revised 8/15/2018 140 of 141

APPENDIX C
Safety Assessment Severity Levels
1 = Minor
The deficiency poses a risk of injury (minor first aid) or there is a
documentation gap.
2 = Intermediate
The deficiency poses a risk of:
1) an injury requiring medical treatment beyond first aid
2) a violation of regulation or University policy (not documentation related)
and/or
3) minor property damage involving equipment or intellectual property where
the loss is limited to the area being inspected and there is no long term impact.
3 = Severe
The deficiency poses a:
1) an immediate risk to life
2) risk of an environmental release that could result in a Notice of Violation
(NOV)
3) risk of a significant property damage involving equipment or intellectual
property where the loss could affect other areas and the impact is long term.
BMP = Best Management Practice

While an item may be in compliance with regulation a best practice is
recommended. This a non-mandatory action.
Revised 8/15/2018 141 of 141

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University of Notre Dame Safety Assessment Program

Safety Assessment Checklist

Q# Question Weight Requirement

Is fall arrest equipment worn by persons working from aerial lifts

Are pre-use equipment inspections and workplace inspections

1.5 Are personnel who work on scaffolds trained? 3 1926.454(a)

1.6 Other 1 N/A

Q# Question Weight Requirement

Have all affected employees who may in the course of

2.2 Are areas containing ACMs properly labeled? 3 1910.1001(j)(5)

Revised 8/15/2018 1 of 141

Q# Question Weight Requirement

Do truck battery charging areas at the site meet the following

• Areas are designed and properly equipped;

• Workers are required to wear goggles, face shield, and

BBP & Sharps

Q# Question Weight Requirement

Revised 8/15/2018 2 of 141

Is contaminated laundry handled as little as possible with a

Is contaminated laundry placed and transported in bags or 29 CFR 1910.1030(d)

Is PPE used when handling contaminated laundry?

Within 10 days of initial assignment, is the hepatitis B vaccination

Are individuals who are reasonably anticipated to have contact

4.7 Other 1 N/A

Q# Question Weight Requirement

Revised 8/15/2018 3 of 141

Have personnel received training on incident reporting and their

Are containers of hazardous chemicals is labeled, tagged or

Each container of hazardous chemicals is labeled with the

5.3 Is a documented inventory of all chemicals taken annually? 2 1910.1200(e)(1)(i)

Revised 8/15/2018 4 of 141

Are personnel trained on hazardous chemicals in their work area

Are flammable or combustible liquids stored in proper containers?

Have methods been developed to inform employees of the 29 CFR 1910.1200(e)

Revised 8/15/2018 5 of 141

5.9 Are incompatible chemicals/wastes segregated appropriately? 1 None

Is dry ice stored in a well-ventilated location (no walk-in freezers

Have personnel who ship packages containing dry ice been

Q# Question Weight Requirement

Do compressed gas cylinders meet the following requirements (as

• Cylinders are secured at all times to prevent tipping, falling, or

6.2 Other 1 N/A

Revised 8/15/2018 6 of 141

Q# Question Weight Requirement

Are visual inspections and functional checks conducted prior to

Are documented inspections conducted of cranes, hoists, ropes,

Are all under-hook lifting attachments in safe working order,

Are crane, hoist operators and maintenance personnel properly

Confined Space Entry

Q# Question Weight Requirement

Revised 8/15/2018 7 of 141

Before entry operations begin, has a permit been properly

Are permits retained for recordkeeping?

Is signage present at the CS that informs employees of permit

If confined space has been reclassified to a non-permitted space

When contractors are performing CS entry, are documented Confined Space

Revised 8/15/2018 8 of 141

Q# Question Weight Requirement

Is there a housekeeping program to manage the dust

9.4 Other 1 N/A

Emergency Action Plan

Q# Question Weight Requirement

Revised 8/15/2018 9 of 141