Approved By: / Director / Effective Date: / 5/17/16
Changes Made: / Added Information Box including Location, Inspector and Date / Time. Change of format from previous version
Visual Housekeeping Inspection Form
Fire Prevention / Extinguishers / Sat Unsat N/A / Electrical: / Sat Unsat N/A
Exit path clear & accessible / Extension cords are 3 wire type
Exit marked & easily identified / Conditions of plugs & wall outlets
Fire escapes clear & in good condition / Electrical switch panel clear (36”)
Trash & excess waste maintained/removed / Surge protector with built-in breaker
Fire evacuation charts posted / Surge protector in single use & outlet
Fire ext. annual inspection completed / Space Heaters: / Sat Unsat N/A
Fire ext. properly charged on indicator / Approved 150v max only
Fire ext. properly distanced (75’ & 50’) / Tip over safety protection & fan driven
Fire ext. monthly inspection completed / UL approved with auto temp shut-off
Fire ext. marked, path clear & accessible / Floors and Aisles: / Sat Unsat N/A
Fire sprinklers have free clearance (18”) / Walk-ways clear of trip hazards
Eyewash: / Sat Unsat N/A / Carpets/Mats properly secured
Monthly inspection completed / Aisles cleared of obstructions
Stations are in good condition / Stairs/Ladders/Ramps: / Sat Unsat N/A
Clear path is maintained and accessible / Adequate lighting
Portable stations are properly mounted / Stair treads in good condition
HazCom: / Sat Unsat N/A / Handrails in good condition
Containers are properly labeled / Ladder parts in good condition
MSDS’s up to date & accessible / Ramps have nonskid surfaces/guard rails
General Conditions: / Sat Unsat N/A / Additional Items: / Sat Unsat N/A
File cabinets/drawers closed or secured / Employee safety awareness
Shelves properly loaded & secured / Adequate PPE available
Fan guards in place / Recycling containers being used
Applicable warning signs posted & legible / Mechanical rooms kept clear
Ventilation operating properly / Other: / Sat Unsat N/A
First aid kits labeled, inspected, & accessible
Crane/Hoist: Updated Inspection Chain Bag Controls labeled Straps in good condition
Comments/Recommendations: / Date problem was corrected:
Location: ______Inspector: ______Date/Time: ______
This OHSAS document was printed on 5/18/2016 and may no longer represent the current revision.
The current revision can be verified on the City Intranet Web page: Safety Forms Page 1 of 1