Staffing Services Client Evaluation Form

Transcription

1 Staffing Services Client Evaluation Form Client Name: Location: Contact(s): Completed By: A Safety Performance Experience Modification Factor? OSHA 300 Logs Available? # Of Injuries/Illnesses? Types of Accidents? Any identified loss trends? Any Dept. with excessive injuries? Job Class Code for Employees? B Accident/Injury Management Procedures for Reporting Accidents/Injuries? Medical Facility Used? First Aid Capabilities on Premises? Accident Investigated for Root Cause? View form. Contact Person for Injury Follow-up? Can You Accommodate Modified Duty? C Safety Program Safety Manual/Employee Handbook? Yes No N/A Written Safety Policy? Yes No N/A Written Safety Rules? Yes No N/A Employees receive specific listing of safety rules? Yes No N/A Safety Orientation? By Who? Yes No N/A Scheduled Refresher Safety Training? Yes No N/A Bi-lingual supervisors? Yes No N/A Date: LC-0440 Rev. 03/16 Page 1

2 Hazardous Communication Program Yes No N/A Written Program Available? Yes No N/A List of Chemicals? Yes No N/A MSDS Available? Yes No N/A Chemical Containers Clearly Labeled? Yes No N/A Training Program? Yes No N/A Machine Guarding & Lock Out Tag Out Yes No N/A Points of Operation/Moving Parts Guarded? Yes No N/A Transmission Apparatus/Pinch Points Guarded? Yes No N/A Machine Safeguarded Reviewed with Employee(s)? Yes No N/A Written Lock Out Tag Out Program? Yes No N/A Designated and Affected Employees Trained? Yes No N/A Operating Controls Clearly Labeled? Yes No N/A Emergency Stop Available? Yes No N/A Environmental Exposures Yes No N/A Air Quality Concerns (dust, spray paint, etc.)? Yes No N/A Noise Exposure > 85 dba? Yes No N/A Employees in High Noise Area Given Baseline Yes No N/A (Upon Placement) & Annual Audiometric Testing? Hot/Cold Temperatures/Wet Environment? Yes No N/A Industrial Trucks (i.e. Forklifts) Yes No N/A Designated Operators? Yes No N/A Operators Certified? Yes No N/A Regular Operator Safety Training? Yes No N/A Frequency of Training? Yes No N/A Truck Trailers Wheels Chocked & Secured to Dock? Yes No N/A Observe Safe Industrial Truck Operation? Yes No N/A Employee Placement Near High Industrial Truck Traffic? Yes No N/A LC-0440 Rev. 03/16 Page 2

3 Hoists and Auxiliary Equipment Yes No N/A Designated Operators? Yes No N/A Operator Training? Yes No N/A Controls Plainly Marked for Direction of Travel? Yes No N/A Ropes, Slings, Hooks in Good Condition? Yes No N/A Fire Safety Yes No N/A Emergency Evacuation Program? Yes No N/A Emergency Evacuation Training for Employees? Yes No N/A Emergency Drills Conducted? Yes No N/A Exits Marked with Illuminated Signs? Yes No N/A Paths to Exits Free of Obstructions Yes No N/A Sufficient Number of Exits Available? Yes No N/A Electrical Wiring Deficiencies? Yes No N/A Accessible Fire Extinguishers? Yes No N/A Employee Fire Extinguisher Training? Yes No N/A NO SMOKING Signs & Enforced? Yes No N/A Safe Welding Practices? Yes No N/A Hand Tools and Equipment Yes No N/A Tools in Good Condition? Yes No N/A Tools & Equipment Regularly Inspected? Yes No N/A Grinders, Saws & Portable Tools Properly Yes No N/A Guarded? Rotating/Moving Parts Adequately Guarded? Yes No N/A Openings & Elevated Work Surfaces Yes No N/A Guardrails & Perimeter Protection for Platforms, Balconies and Floor Openings? Yes No N/A Stairs Slip Resistant? Yes No N/A Stair Handrails? Yes No N/A Stairways Well Lit? Yes No N/A LC-0440 Rev. 03/16 Page 3

4 Housekeeping Yes No N/A Aisles Clear and Well Marked? Yes No N/A Water, Oil or Other Liquids on Floor? Yes No N/A Ice & Snow Removal for Sidewalks & Lots? Yes No N/A Adequate Lighting? Yes No N/A Wet Surfaces Slip Resistant? Yes No N/A D Ergonomic Information How are ergonomic concerns assessed and corrected? Repetitive Hand/Wrist/Arm Movement Required? Repetitious 2000 hand movements/hr continuous Excessive Reaching, Pulling? Bending, Stooping, Twisting, Motions for Extended Time? Standing for Extended Period of Time Excessive or Extreme Vibration? Weight Lifted or Carried / frequency of? Up to 10 Pounds? 11 to 25 Pounds? 26 to 50 Pounds? If > 50 Pounds, # of Pounds? Lifting Objects Between Knuckle & Shoulder Height? Lifting Devices Available & Used? E Personal Protective Equipment (PPE) Required? Provided? Enforced? Designated PPE areas appropriately marked? Yes No Goggles/Face Shield Yes No Yes No Yes No Safety Glasses Yes No Yes No Yes No Gloves/Aprons Yes No Yes No Yes No Hard Hats Yes No Yes No Yes No Foot Protection Yes No Yes No Yes No Respirators Yes No Yes No Yes No Hearing Protection Yes No Yes No Yes No LC-0440 Rev. 03/16 Page 4

5 F - Miscellaneous Dedicated supervisor for area where EE's will work? Number of Client Employees? Number of Staffing Service Employees Used? Number Requested of Our Staffing Agency? Reason for Utilizing Our Services? Hiring Temp to Perm placement? Hiring day labor work positions? Time Keeping (Punch Card/Swipe Card, etc.) What Entrance to be Used By Staffing Employees? Designated Smoking Areas? Lunch Room Provided? Lockers/Safe Storage of Personal Items? Work at heights? Explain Will employee operate machines? Explain Will employee assist machine operators? Explain Will employee drive any vehicles (auto/truck)? Explain Will the EE be operating any power machinery/tools? Is there a procedure to identify, evaluate, and correct workplace hazards G Temporary Employees Initial Safety Training? Client Staffing Agency Specific hands on safety training for job hazards? Yes No N/A Specific hands on safety training for new job hazards? Yes No N/A General Safety Policy, Rules & Procedures? Yes No N/A Hazardous Communication? Yes No N/A Machine Guarding? Yes No N/A Lock Out/Tag Out? Yes No N/A Emergency Evacuation? Yes No N/A Fire Safety? Yes No N/A PPE? Yes No N/A Hearing Conservation? Yes No N/A Bloodborne Pathogens? Yes No N/A Electrical? Yes No N/A LC-0440 Rev. 03/16 Page 5

6 G Temporary Employees Initial Safety Training? (continued) Client Staffing Agency Hoists & Slings? Yes No N/A Hand Tools Inspection? Yes No N/A Housekeeping? Yes No N/A Safe Lifting Techniques? Yes No N/A H Additional LC-0440 Rev. 03/16 Page 6