Safety And Health Program Assessment Worksheet
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11Safety and Health Program Assessment Worksheet - Blank Form 33
Safety and Health Program Assessment Worksheet
Blank Form 33
Request Number
Visit Number
Visit Date
Employer
Site Location
Legend: 0 = No; 1 = No, Needs major improvement; 2 = Yes, Needs minor improvement; 3 = Yes;
NA = Not Applicable; NE = Not Evaluated
* = Stretch Items Attribute of Excellence
Hazard Anticipation and Detection
0
1
2
3
NA
NE
1. A comprehensive, baseline hazard survey has been conducted
within the past five (5) years.
Comments:
2. Effective safety and health self-inspections are performed
regularly.
Comments:
3. Effective surveillance of established hazard controls is
conducted.
Comments:
4. An effective hazard reporting system exists.
Comments:
file:///C|/Documents and Settings/pzark.000/Desktop/Download/form33_blank.html (1 of 11) [4/15/2003 9:45:45 AM]
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Parent category: Business