Health %26 Safety Compliance Form
Health & Safety Compliance Form
This Health & Safety Compliance Form is designed to evaluate and ensure adherence to safety standards. Use it to assess worksite conditions, identify hazards, review procedures, and implement corrective actions.
Organization Name
Location
Date of Assessment
Inspector's Name
Job Title
Department/Area Being Assessed
I. Compliance Areas
A. Worksite Conditions
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Criteria |
Compliant |
Non-Compliant |
Not Applicable |
Comments |
|---|---|---|---|---|
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Cleanliness |
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Maintenance |
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Environmental Factors |
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Lighting and Ventilation |
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B. Hazard Identification
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Criteria |
Compliant |
Non-Compliant |
Not Applicable |
Comments |
|---|---|---|---|---|
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Physical Hazards |
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Chemical Hazards |
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Biological Hazards |
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Ergonomic Risks |
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C. Safety Procedures
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Criteria |
Compliant |
Non-Compliant |
Not Applicable |
Comments |
|---|---|---|---|---|
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Emergency Response |
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Equipment Usage |
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Personal Protective Equipment (PPE) |
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Safety Signage and Labels |
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D. Training and Awareness
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Criteria |
Compliant |
Non-Compliant |
Not Applicable |
Comments |
|---|---|---|---|---|
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Safety Training Programs |
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Employee Awareness |
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Documentation and Records |
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II. Inspection Findings
Overall Compliance
Review and summarize overall compliance status here. Note key findings, issues, and any non-compliance areas that need addressing.
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Generally compliant with minor issues.
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Compliant with significant findings.
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Partially compliant.
Key Issues
Identify and describe key issues found during the assessment. Highlight significant non-compliance areas and any critical concerns requiring action.
III. Action Plan
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Action |
Responsible Person |
Deadline |
|---|---|---|
