Evaluator Name: [Your Name]

Date of Evaluation: [April 9, 2053]

Location of Evaluation: [Your Company Address]

Document Number: [DC-123345]

Safety Procedures

1.Adequacy of safety procedures and guidelines

• 5 - Excellent

• 4 - Very Good

• 3 - Good

• 2 - Poor

• 1 - Very Poor

2. Proper training for employees.

• 5 - Excellent

• 4 - Very Good

• 3 - Good

• 2 - Poor

• 1 - Very Poor

Emergency Response

3. Availability of emergency equipment

• 5 - Excellent

• 4 - Very Good

• 3 - Good

• 2 - Poor

• 1 - Very Poor

4.  Emergency response plan in place

• 5 - Excellent

• 4 - Very Good

• 3 - Good

• 2 - Poor

• 1 - Very Poor

Hazard Identification

5. Identification and mitigation of workplace hazards

• 5 - Excellent

• 4 - Very Good

• 3 - Good

• 2 - Poor

• 1 - Very Poor

6. Personal Protective Equipment (PPE).

• 5 - Excellent

• 4 - Very Good

• 3 - Good

• 2 - Poor

• 1 - Very Poor

Safety Inspections

7. Regular safety inspections and audits

• 5 - Excellent

• 4 - Very Good

• 3 - Good

• 2 - Poor

• 1 - Very Poor

8. Follow-up on inspection findings

• 5 - Excellent

• 4 - Very Good

• 3 - Good

• 2 - Poor

• 1 - Very Poor

Overall Safety Rating

Based on the above assessments, rate the overall safety of the area/product/event.

• 5 - Excellent

• 4 - Very Good

• 3 - Good

• 2 - Poor

• 1 - Very Poor

Comments and Recommendations

Please provide any comments or recommendations for improving safety:

Evaluator's Signature: 

Date: [Insert Date]

Acknowledgment:

I acknowledge that the information provided in this Safety Evaluation Form is accurate and reflects the safety standards in accordance with US laws and regulations.

[Your Name]

[Insert Date]