ADMINISTRATIVE REQUIREMENTS

YES NO
1. Is the Department of Labor and Employment job safety
and health protection poster (or a facsimile) posted in a
______ ______
conspicuous place?

Why:

2. Are all occupational deaths, injuries, and illnesses

recorded on the DOLE form 200 as required? ______ ______

Why:

3. Is each recordable injury entered on the OSHA 200

within 6 working days of the employer learning the
______ ______
injury?

Why:

4. Is the DOLE 200 summary for previous year posted

from February 1 to March 1? ______ ______
 Why:

5. Is a DOLE form 101 (or its equivalent), supplemental

record of each occupational injury or illness, available
______ ______
at the establishment?

Why:

6. Is the DOLE Area Director notified with forty-eight hours

of any employment fatality or any accident which
______ ______
results in the hospitalization of five or more employees?

Why:
 GENERAL SAFETY AND HEALTH

YES NO
1. Each employee instructed in the recognition and
avoidance of unsafe conditions and regulations
applicable to his work environment to control or
______ ______
eliminate any hazard or other exposure to illness or
injury?

Why:

2. Are employees who are required to handle or use

poisons, caustics, and other harmful substances
instructed in their safe handling and use, and made
aware if the potential hazards, personal hygiene, and ______ ______
personal protective measures?

Why:

3. Are employees who are required to enter confined or

enclosed spaces instructed as to the nature of the
hazards involved, the necessary precautions to be
______ ______
taken and in the use of protective and emergency
equipment?
 Why:

4. If form and scrap lumber with protruding nails and all

other debris kept cleared from work areas,
______ ______
passageways, and stairs?

Why:

5. Are employees required to wear appropriate personal

protective equipment when there is an exposure to
______ ______
hazardous conditions?

Why:
 MEDICAL SERVICES, FIRST AID, SANITATION

YES NO
1. Is a facility for the treatment of injured employees
located within three minutes from the job site? If not, is
______ ______
there an employee(s) trained if first aid at the site?

Why:

2. Are first aid supplies that are approved by the

consulting physician readily accessible? ______ ______

Why:

3. Are telephone numbers of physicians, hospitals, or

ambulances conspicuously posted? ______ ______

Why:
4. Are potable (drinking) water and adequate toilet
facilities available in the job site? ______ ______

Why:

5. Are the regulations concerning protection of employees

against the effects of noise exposure understood and
______ ______
complied with?

Why:
 HAZARD COMMUNICATION

YES NO
1. Does employee have a written Hazard Communication
Program? ______ ______

Why:

2. Does employer have a complete list of hazardous

chemicals used on site? ______ ______
Does list reference appropriate DOLE?

Why:

3. Does employer either:

A. Provide other employers who may have exposed

______ ______
employees with DOLE or
B. Make DOLE available at a central worksite location?
______ ______
 Why:

4. Does employer inform other employers of any

precautionary measures they may need to take? ______ ______

Why:

5. Does employer inform other employers of labeling

system? ______ ______

Why:

6. Are containers of hazardous chemicals, labeled, tagged

or marked? ______ ______
 Why:

7. Does labeling include both:

a) identify b) hazard warning? ______ ______

NOTE: Labels need not to be used on portable containers to

be immediately used by employee making transfer.
Why:

8. Does employer have an MSDS for each hazardous

chemical on site? ______ ______

Why:

9. Are DOLEs available to employees?

______ ______
 Why:

10. Are employees trained in the hazard of chemical in

their work area?
______ ______

Why:

11. Does training include:

A. Hazard communication standard requirements?

______ ______
Why:

B. Any operation in employees area where hazardous

chemicals may be present? ______ ______
Why:

C. Location and availability of Hazard Communication

Program ______ ______

Why:

D. Methods that may be used to detect a chemical

release? ______ ______

Why:

E. Physical and chemical hazards of chemicals in the

workplace ______ ______

Why:

F. Measures employees can take to protect

themselves? ______ ______
G. Details of employers Hazard Communication
Programs?
(labeling, DOLE, how to obtain and use information)
______ ______

Why: