Company Name:
Representative's Name:
Email:
Phone Number:
1. Does your organization have a health and safety policy statement? YesNo
1. Are hazard assessments conducted, documented, and approved by senior management for all operations?YesNo
2. Do you have a list of identified critical tasks? YesNo
1. Have Safe Work Practices been documented? YesNo
1. Have Safe Job Procedures been documented? YesNo
1. Are company rules clearly stated in writing and provided to each employee? YesNo
2. Do you have a progressive discipline procedure? YesNo
1. Is there a written policy governing mandatory use of PPE? YesNo
1. Do you have a preventative maintenance program for facilities, tools, equipment and vehicles? YesNo
2. Do you have a list of inventory items to be maintained? YesNo
3. Is maintenance being performed as planned? YesNo
1. Do you have a documented orientation program? YesNo
2. Is job specific training provided and are records retained? YesNo
3. Is all required training up-to-date? YesNo
4. Are records of safety meetings retained? (i.e. tool box talks, Joint health and safety committee) YesNo
1. Do you have a documented workplace inspection procedure? YesNo
2. Are specific forms and or checklists used for recording inspections? YesNo
1. Do you have a documented policy and procedure for the investigating and reporting of incidents, accidents, near-misses etc.? YesNo
1. Do documented emergency preparedness and emergency response plans include the most appropriate responses to identified hazards and address the potential for emergency situations? YesNo
2. Do the plans define the roles and responsibilities of relevant personnel? YesNo
3. Have appropriate emergency response resources and equipment been made available? YesNo
1. Is there a document procedure to organize monitor and measure Occupational Health & Safety performance? YesNo
2. Is occupational health and safety performance being measured at a specified frequency? YesNo
3. Are monthly and annual summaries of health and safety statistics available? YesNo
1. Is health and safety legislation (all acts regulations and apply. considered during the job planning process? YesNo
2. Have supervisors and workers been trained on their rights and responsibilities and how to exercise them? YesNo
1. Has the organization conducted risk assessments for occupational health hazards? YesNo
2. Is there a documented procedure that addresses working safely with chemicals, physical agents, biological agents, lead, asbestos, silica etc.? YesNo
1. Is there a documented procedure for the provisions and maintenance of first aid that includes qualified first aid or posting first aid training certificates and a process for maintaining and recertifying first aid attendance? YesNo
1. Do you have a joint health and safety committee? YesNo
2. Does your organization have documented procedures for the selection of roles and responsibilities in the establishment criteria for joint health and safety committees? YesNo
1. Does your organization have a workplace violence and harassment policy statement that is current, is reviewed annually, and is visibly posted in the workplace or made available to the workers? YesNo
1. Does your organization have a written return to work and reemployment policy and procedure? YesNo
1. Does the senior management have a policy for conducting an annual review of the organizations Occupational Health & Safety program? YesNo
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