HAZARDS (Specify the department(s) where these hazards are found and describe problem in the space provided)
__ 1. Too hot ____________________________________________________________
__ 2. Too cold or drafty ____________________________________________________
__ 3. Sudden temperature changes ____________________________________________
__ 4. Poor lighting ________________________________________________________
__ 5. Obstruction in aisles __________________________________________________
__ 6. Exposed wires or other electrical problems ________________________________
__ 7. Wet or slippery floor __________________________________________________
__ 8. Faulty handjack _____________________________________________________
__ 9. Forklift in poor condition ______________________________________________
__ 10 Have you had any training to operate forklift ______________________________
__ 11. Inadequate ventilation________________________________________________
__ 12. Machines lacking guards ______________________________________________
__ 13. Machines poorly maintained ___________________________________________
__ 14. Improper storage of dangerous materials _________________________________
__ 15. Excessive noise _____________________________________________________
__ 16. Excessive vibration __________________________________________________
__ 17. Machines poorly maintained ___________________________________________
__ 18. Poor housekeeping or inadequate: ______________________________________
__ Bathroom ______________________________________________________
__ Change areas ____________________________________________________
__ Lunch rooms ____________________________________________________
__ 19. Heavy lifting _________________________________________________________
__ 20. Repetitive work ______________________________________________________
__ 21.Inadequate protection from fire _________________________________________
__ 22. Inadequate or unclear marked Emergency Exits ___________________________
__ 23. Workers inadequately trained for jobs ___________________________________
24. Do you work with chemicals? Yes___ No___
What kind/what are they used for _____________________________________
Did you receive proper training on the chemicals you work with? Yes___ No___
25. Does the company always provide, at no cost, the appropriate safety equipment like gloves, protective hearing devices, helmet, etc? Yes___ No___
26. Is there a first-aid kit station or rest area in your shop? Yes___ No___
27. Are medical personnel available or persons trained in first-aid kit? Yes___ No___
HEALTH & SAFETY SURVEY
Name (optional)
Work location and department
Job title __________________________ # of years in this position _____
Hourly wage _______
1. Have you ever been injured or became sick because of working conditions?
Yes___ No___
2. If yes what type of injury or illness?
__ Burns | Describe problem: _________________________
__ Cuts | Describe problem: _________________________
__ Eye injury | Describe:__________________________________
__ Hearing loss | Describe:__________________________________
__ Back injury
__ Muscle strain | Describe:__________________________________
__ Broken bones | Describe:__________________________________
__ Throat/lung problems | Describe:__________________________________
__ Skin problems/allergies | Describe:__________________________________
__ Nausea/dizziness/headaches | Describe:__________________________________
__ Anxiety/irritability/unusual fatigue ________________________
3. What caused your injury or illness? :__________________________________
4. Did you report your injury or illness? __ yes ___ no
5. Did you miss time at work as a result of your injury or illness? Yes___ No___
How much time did you miss at work? ______________
6. Did you receive workers' compensation? __ yes ___ no