General Information

Name:

[Your Name]

Position:

Employee ID:

Physical Environment Assessment

Workspace Layout:

Is the layout conducive to safe and efficient work? (Yes/No)

Yes

Comments:

Lighting and Ventilation:

Is the lighting adequate for safe working? (Yes/No)

Is the ventilation system effective? (Yes/No)

Comments:

Noise Levels:

Are noise levels within safe limits? (Yes/No)

Comments on noise level issues:

Equipment and Machinery Safety

Condition of Equipment:

Is all equipment in good working condition? (Yes/No)

List any equipment needing maintenance:

Safety Measures:

Are safety measures for equipment use posted and followed? (Yes/No)

Training and Usage:

Have employees been trained in safe equipment usage? (Yes/No)

Comments on training adequacy:

Health and Safety Practices

Emergency Procedures:

Are emergency exits and fire safety equipment marked and accessible? (Yes/No)

Is there a well-understood emergency response plan? (Yes/No)

Hazardous Materials:

Are hazardous materials stored and handled safely? (Yes/No)

Comments on hazardous material practices:

PPE Usage:

Is appropriate Personal Protective Equipment available and used correctly? (Yes/No)

Comments on PPE usage:

Employee Wellness and Comfort

Ergonomics:

Do workstations support ergonomic safety? (Yes/No)

Comments on ergonomic improvements needed: 

Employee Feedback:

Summary of employee feedback on workplace environment:

Health and Wellness Programs:

Are health and wellness resources/programs available to employees? (Yes/No)

Comments on health and wellness support: