Prepared by:

[Your Name]

Date:

[Month Day, Year]

Section

Criteria

Compliance Level

Remarks/Evidence Required

General Safety

Proper signage, emergency exits, fire extinguishers

Compliant /

Non-Compliant / Partially Compliant

Photos, inspection dates

Employee Training

Regular training sessions, training records

Compliant /

Non-Compliant / Partially Compliant

Training schedules, attendance records

Equipment Safety

Regular maintenance, safety checks

Compliant /

Non-Compliant / Partially Compliant

Maintenance logs, safety check records

Hazardous Materials

Proper storage, handling procedures

Compliant /

Non-Compliant / Partially Compliant

Storage protocols, training on handling

Personal Protective Equipment (PPE)

Availability and use of PPE

Compliant /

Non-Compliant / Partially Compliant

Inventory logs, usage guidelines

Health & Safety Policies

Updated and accessible policies

Compliant /

Non-Compliant / Partially Compliant

Policy documents, revision dates

Incident Reporting

Effective reporting system, follow-up

Compliant /

Non-Compliant / Partially Compliant

Incident logs, follow-up actions

Ergonomics & Workplace Design

Comfortable, safe workspace design

Compliant /

Non-Compliant / Partially Compliant

Workspace layout plans, employee feedback

Environmental Health

Waste management, air quality

Compliant /

Non-Compliant / Partially Compliant

Waste disposal records, air quality reports

Health & Wellness Programs

Employee wellness initiatives

Compliant /

Non-Compliant / Partially Compliant

Program details, participation rates