Health & Safety Workplace Evaluation Form

Evaluation Date	[January 1, 2050]
Evaluator's Name	[Your Name]
Department/Section	[Operations]

General Information

• Office

• Warehouse

• Production Area

• Other:                               

Section 1: Workplace Environment

1. Lighting

• Adequate

• Inadequate

• Comments:                               

                                                                                                                                                                                                                                                                                  

2. Ventilation

• Adequate

• Inadequate

• Comments:                               

                                                                                                                                                                                                                                                                                  

3. Noise Levels

• Acceptable

• Excessive

• Comments:                               

                                                                                                                                                                                                                                                                                  

4. Cleanliness and Hygiene

• Satisfactory

• Unsatisfactory

• Comments:                               

                                                                                                                                                                                                                                                                                  

Section 2: Equipment and Machinery

1. Condition of Equipment

• Good

• Needs Maintenance

• Comments:                               

                                                                                                                                                                                                                                                                                  

2. Safety Guards in Place

• Yes

• No

• Comments:                               

                                                                                                                                                                                                                                                                                  

3. Emergency Shut Offs Accessible

• Yes

• No

• Comments:                               

                                                                                                                                                                                                                                                                                  

Section 3: Fire Safety and Emergency Procedures

1. Fire Extinguishers

• Adequate Number

• Insufficient

• Comments:                               

                                                                                                                                                                                                                                                                                  

2. Evacuation Routes

• Clearly Marked

• Not Clearly Marked

• Comments:                                

                                                                                                                                                                                                                                                                                  

3. Emergency Lighting

• Functional

• Non-Functional

• Comments:                               

                                                                                                                                                                                                                                                                                  

Section 4: Personal Protective Equipment (PPE)

1. Availability of PPE

• Sufficient

• Insufficient

• Comments:                               

                                                                                                                                                                                                                                                                                  

2. Usage of PPE

• Always Used

• Sometimes Used

• Never Used

• Comments:                               

                                                                                                                                                                                                                                                                                  

Section 5: Training and Awareness

1. Safety Training

• Regularly Provided

• Not Provided

• Comments:                               

                                                                                                                                                                                                                                                                                  

2. Awareness of Safety Procedures

• High

• Moderate

• Low

• Comments:                               

                                                                                                                                                                                                                                                                                  

Additional Observations

Evaluator's Signature:

Date: [Month Day, Year]

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