Host Agency Safety Assessment Checklist
Created: 12/27/12Participant Name: Date Assessment Completed:Host Agency Name/Address: Date Participant Assigned:Host Agency Supervisor Name:
Potential Hazardous Conditions/Areas and Items to Survey
(S=Satisfactory; U=Unsatisfactory; NA=Not Applicable) S U NAHas your supervisor here talked with you about safety and what to do in case of emergency?Do you know where the nearest exit is?Have you been assigned a “buddy” to assist you in case of an emergency? (only applicable for participants with special needs)Do you know where the fire extinguisher is?Do you know what the procedures are in case of a fire?Do you know how to report an injury on the worksite?Please explain how you should report an injury?
Walkways, Steps, Entrance way and Parking areasAre the floors defective?( broken tile, loose carpeting)Are sidewalks or parking areas free of: (potholes, cracks and debris?)Are there defective stairs or handrails?Are wet mats used and in good condition during rain/snow season?Are wet floor signs used?Does the participant know where or how to use the wet floor signs?Is there an adequate snow/ice removal plan in place?If needed does the participant have an alternate entrance way during snow/ice conditions?
Stairways, Hallways, and Common areasIs there emergency lighting?Are the stairways free of debris? (i.e. boxes, storage in walkway)Do the stairways have non-slip treads?Are the handrails sturdy?Are the emergency exit signs clearly marked and exit doors accessible? (not blocked)Are there any wet floors?(check near water coolers, coffee machines, break rooms, rest rooms- anywhere spills can occur)Is there an emergency evacuation plan in uses and practiced (fire drills, etc.)?
Primary work area used by the participantIs the participants station properly set up? Adjustable chairs, desks keyboards, mouse pads?Is the area free from potential slips, trips and falls( are desk drawers shut, electrical cords and telephone cords routed away from
walking areas and secured under the desk our of the way of feet?)Are extension cords used (this can be a fire hazard?)Are the following acceptable for the participants work environment? (Space condition, noise level, air quality/temperature, general
cleanliness and housekeeping.)
This checklist should be completed on an annual basis at the host agency with the participant and host agency supervisor. Please base your
responses to the actual walk through of the facility and the participant and host agency responses.
Note: This form must be completed by a SCSEP Project Staff. Host Agency Safety Assessment Checklist
Created: 12/27/12
Potential Hazardous Conditions/Areas and Items to Survey
(S=Satisfactory; U=Unsatisfactory; NA=Not Applicable) S U NA
Machinery, Tools and personal Protective equipmentSelection of the right tools: Are tools in good working condition?Are the right tools provided to the participant to complete the task? (Examples: head phones for a lot of phone work, extension wands
for dusting blinds and hard to reach places, cutting boards, sharp knives, oven mitts, gloves, safety glasses, long sleeves and long pants
for outdoor work.) Has there been any new equipment/machinery introduced that the participant has not been trained to use?
Proper footwearDoes the participant know what type of footwear is proper for the host agency assignment? Are safety shoes worn for landscaping or construction type work?Are non-slip shoes worn in housekeeping and food service type work?
Training and Lifting RequirementsHave participants been training in their duties prior to beginning new tasks? Have participants been trained in emergency procedures?Are participant aware of the lifting requirement for the Host Agency? If so, the participant may not lift more than______lbs.
Comments/Corrective Actions
SCSEP Project Staff Signature:Include positive feedback as well as items for improvement with planned date for corrective action in this section of the form.
Participant Signature:
Host Agency supervisor Signature:
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