Employee Safety Review Checklist Template printable pdf download

Employee Safety Review Checklist Template

Employee’s Safety Review

Add this safety review to the employee’s performance appraisal. A candid response to each question is

encouraged. Include relevant comments as needed.

Circle One (Scoring 1 = Poor, 2 = Below Average, 3 = Average, 4 = Above Average, 5 = Outstanding

1 2 3 4 5

Does the employee demonstrate a desirable attitude toward safety?

1 2 3 4 5

Does the employee demonstrate knowledge of the safety responsibilities of the job?

Comment –

1 2 3 4 5

Does the employee effectively carry out the safety responsibilities?

Comment –

1 2 3 4 5

Does the employee actively pursue correction of any safety hazards and/or violations

that he/she is aware of, especially within their area of responsibility?

Comment –

1 2 3 4 5

Does the safety record of the employee’s subordinates* indicate that he or she has

given proper instruction, training and follow-up?

Comment -

* If there are no subordinates, rate a 3.

Rating:

A score of 20 or more is considered excellent for this review.

A score of 15 or more is desirable for a positive review.

A score of 10-14 is acceptable but the employee should be encouraged to improve by

the next review.

A score of less than 10 demonstrates a serious deficiency in the area of safety. Initiate

counseling, training, or other means of improving the safety habits and performance of

the employee.

October 2013

Employee Safety Review Checklist Template