GENERAL INDUSTRY SELF-INSPECTION FORM

Person conducting inspection_________________________________________Date of inspection______________

Name of facility_______________________________________Location_________________________________

Description of operations________________________________________________________________________

EXPOSURES                      N/A         Sat.         Needs
                                                                            Action	EQUIPMENT                     N/A         Sat.        Needs
                                                                           Action	
1. Fire protection                              ____          ____            ____
2. Compressed gasses                       ____          ____            ____
3. Flammables                                  ____          ____            ____
4. Hazardous waste                          ____          ____            ____
5. Welding/cutting                           ____          ____            ____
6. Chemicals                                    ____          ____            ____
7. Exits                                             ____          ____            ____
8. Walking surfaces                          ____          ____            ____
9. Floor landings                               ____          ____            ____
10. Railings                                       ____          ____            ____
11. Stairs                                           ____          ____            ____
12. Spray finishings                          ____          ____            ____
13. Fleet of vehicles                          ____          ____            ____
14. _____________                          ____          ____            ____	15. Ladders                                       ____          ____            ____
16. Material Hoists                           ____          ____            ____
17. Rampways                                  ____          ____            ____
18. Power tools                                 ____          ____            ____
19. Hand tools                                  ____          ____            ____
20. Salamanders                                ____          ____            ____
21. Equipment guards                       ____          ____            ____
22..Equipment maintenance              ____          ____            ____
23..Operating rules posted                 ____          ____            ____
24. Powered industrial trucks            ____          ____            ____
25. Utilities:   gas or electric              ____          ____            ____
26. ___________________               ____          ____            ____
	
PERSONAL                        N/A         Sat.         Needs
PROTECTIVE EQUIP.                                    Action	HOUSEKEEPING.            N/A         Sat.        Needs
                                                                           Action	
27. Hard hats                                   ____          ____            ____
28. Safety shoes                               ____          ____            ____
29. Safety glasses                            ____          ____            ____
30. Gloves                                       ____          ____            ____
31. Respiratory  protection              ____          ____            ____
32. Hearing protection                     ____          ____            ____
33. Safety signs posted                    ____          ____            ____
34. Illumination                               ____          ____            ____
35. Ventilation                                 ____          ____            ____
36. Eye wash/shower                       ____          ____            ____
37. _______________                     ____          ____            ____	38. Debris cleanup                           ____          ____            ____
39. Debris removal                           ____          ____            ____
40. Material storage                          ____          ____            ____

Miscellaneous
41. Hazard Communication               ____          ____            ____
42. Bloodborne Pathogens                 ____          ____            ____
43. Confined Spaces                          ____          ____            ____
44. Lockout/Tagout                            ____          ____            ____
45. Records                                         ____          ____            ____
46. ________________                       ____          ____            ____
47. ________________                       ____          ____            ____	
MANAGEMENT                 Sat.            Needs Action	RECOMMENDATIONS	
48. Accident investigation                 ____               _____
49. Management involvement           ____                _____
50. First Aid                                      ____                _____
51. Adequate supervision                  ____                _____
52. Control of subs                            ____                _____
53. ____________________            ____                _____	No recommendations                                                        _____
Recommendations listed below                                         _____

Recommendations discussed                                             _____
Recommendations not discussed                                       _____

In compliance                                                                     _____	
RECOMMENDATIONS:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________