Employee Safety And Health Record printable pdf download

EMPLOYEE SAFETY AND HEALTH RECORD

The AF Form 55 will be maintained by the supervisor in the work place. For Department of the Air Force civilian personnel, this form may be filed with

AF Form 971, Supervisor's Employee Brief. For military personnel - file with any records. See AFI 91-301.

1. NAME (Last, First, Middle Initial) GRADE

2. SSN

3. ORGANIZATION & OFC SYMBOL AND/OR WORKPLACE IDENTIFIER

5. DUTY TITLE

4. OCCUPATIONAL SERIES OR PRIMARY AFSC

6. HAZARDS ASSOCIATED WITH PRESENT JOB OR TASKS AND WORK AREAS (NOISE, ELECTRICAL SHOCK, RADIATION HAZARDOUS MATERIALS, ETC.)

7. OCCUPATIONAL HEALTH MEDICAL EXAMINATION (OHME) REQUIRED

I MANDATORY ITEMS (To be briefed to all personnel, as applicable)

1. HAZARDS OF THE JOB OR TASKS, AND SAFETY PROCEDURES TO BE FOLLOWED (See Item 6)

2. HAZARDS OF THE WORK AREAS (See Item 6)

3. OSH STANDARDS AND GUIDANCE THAT APPLY TO JOB AND WORK PLACE

4. PERSONAL PROTECTIVE EQUIPMENT THEY WILL NEED AND HOW, WHEN, AND WHERE TO USE IT (To be entered into Sections II and III of this form)

5. LOCATION AND USE OF EMERGENCY AND FIRE PROTECTION EQUIPMENT

6. EMERGENCY PROCEDURES THAT APPLY TO THEIR JOB AND WORK PLACE

7. REPORTING UNSAFE EQUIPMENT, CONDITIONS OR PROCEDURES TO SUPERVISOR IMMEDIATELY

8. LOCATION, SUBMITTING PROCEDURES, AND PURPOSE OF AF FORM 457, USAF HAZARD REPORT (AFI 91-202)

9. MISHAP REPORTING PROCEDURES (AFI 91-204)

10. EMERGENCY TELEPHONE NUMBERS

11. LOCATION AND REQUIRED REVIEW OF APPROPRIATE SAFETY BULLETIN BOARDS, AF VISUAL AIR 91-307

12. LOCATION OF MEDICAL FACILITIES AND PROCEDURES FOR OBTAINING TREATMENT

13. REQUIREMENTS FOR DOCUMENTATION AND NOTIFICATION OF ON-THE-JOB INJURY OR ILLNESS

14. PURPOSE AND FUNCTION OF THE AF FORM 1118, NOTICE OF HAZARD

15. INDIVIDUAL RESPONSIBILITIES FOR ENSURING OWN SAFETY

16. REQUIRED USE OF SAFETY BELTS

17 PERSONNEL RIGHTS (AFI 91-301)

18. AIR FORCE HAZARD COMMUNICATION PROGRAM REQUIREMENTS

19. CONFINED SPACE REQUIREMENTS, IF REQUIRED (AFOSH STANDARD 91-25)

20. MANUAL LIFTING GUIDANCE (AFOSH STANDARD 91-46)

21. JEWELRY SAFETY (AFOSH STANDARD 91-66)

22. POTENTIAL HAZARDS ASSOCIATED WITH THE SURROUNDING LOCAL AREA (If operational activities require travel off installation)

23. OTHER (List in remarks or on continuation sheet, if necessary)

II PERSONAL PROTECTION ISSUED

III PERSONAL PROTECTION PROVIDED IN WORK AREA

1. FOOT PROTECTION

2. ARM/HAND PROTECTION

3. EYE PROTECTION

4. HEARING PROTECTION

5. RESPIRATORY PROTECTION

6. HEAD PROTECTION

7. OTHER (List)

PREVIOUS EDITION MAY BE USED

PAGE 1 OF 2 PAGES

AF IMT 55, 19961101, V3

Employee Safety And Health Record

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