5. Incident Reporting and Investigation 6. Emergency Response Inspection Checklist Date: Site: Department: Manager: Inspected by: Name:: Title: #: Name: #: Keys: for Verification: D=documentation O=observation I=interview/informal chat with employee for Status: C=complete PC=partially complete AR=attention required General Appearance of Area Item Risk matrix score Verification Reference (e.g., standard/Act/ regulations, etc.) Recommendation for correction action and/or long term) based on that reference Person(s) responsible Target/ completion date Status (C, PC, AR) Date of follow-up D O I lighting noise thermal conditions clutter Comments: Safety Item Risk matrix score Verification Reference (e.g., standard/Act/ regulations, etc.) Recommendation for correction action and/or long term) based on that reference Person(s) responsible Target/ completion date Status (C, PC, AR) Date of follow-up D O I three rights rules
Comments: Polices, Safe Operating Procedure, Job Safety Analysis (linked to ergonomics of the task) Item Risk matrix score Verification Reference (e.g., standard/Act/ regulations, etc.) Recommendation for correction action (short and/or long term) based on that reference Person(s) responsible Target/ completion date Status (C, PC, AR) Date of follow-up D O I Comments: Incident Reports and Follow-up Item Risk matrix score Verification Reference (e.g., standard/Act/ regulations, etc.) Recommendation for correction action and/or long term) based on that reference Person(s) responsible Target/ completion date Status (C, PC, AR) Date of follow-up D O I incident report binder Comments: Department Specific Orientation Binder Item Risk matrix score Verification Reference (e.g., standard/Act/ regulations, etc.) Recommendation for correction action (short and/or long term) based on that reference Person(s) responsible Target/ completion date Status (C, PC, AR) Date of follow-up D O I
Comments: Safety Talk Binder (with employee initial) Item Risk matrix score Verification Reference (e.g., standard/Act/ regulations, etc.) Recommendation for correction action (short and/or long term) based on that reference Person(s) responsible Target/ completion date Status (C, PC, AR) Date of follow-up D O I Comments: Training Item Risk matrix Verification Reference (e.g., standard/Act/ regulations, etc.) Recommendation for correction action (short and/or long term) based on that reference Person(s) responsible Target/ completion date Status (C, PC, AR) Date of follow-up D O I TLR GPA WHMIS/GHS Mobile Equipment PART Safety for Supervisors Biological hazards (Universal Precautions) Protection against falling Comments: Equipment
Item Risk matrix score Verification Reference (e.g., standard/Act/ regulations, etc.) Recommendation for correction action (short and/or long term) based on that reference Person(s) responsible Target/ completion date Status (C, PC, AR) Date of follow-up D O I beds patient lifts wheelchairs mixers med carts slings sharps container protection against falling Comments: Equipment Manuals Item Risk matrix score Verification Reference (e.g., standard/Act/ regulations, etc.) Recommendation for correction action (short and/or long term) based on that reference Person(s) responsible Target/ completion date Status (C, PC, AR) Date of follow-up D O I carts/dolly beds patient lifts wheelchairs mixers med carts slings Comments: Department Maintenance Log Book Item Risk matrix score Verification Reference (e.g., standard/Act/ regulations, etc.) Recommendation for correction action (short and/or long term) based on that reference Person(s) responsible Target/ completion date Status (C, PC, AR) Date of follow-up D O I carts/dolly beds patient lifts wheelchairs mixers med
ventilation & heating system lock out system Comments: Personal Protective Equipment Item Risk matrix Verification Reference (e.g., standard/Act/ regulations, etc.) Recommendation for correction action (short and/or long term) based on that reference Person(s) responsible Target/ completion date Status (C, PC, AR) Date of follow-up D O I gloves face shield gowns oven rubber boots Comments: Emergency Response (Preparedness) Item Risk matrix score Verification Reference (e.g., standard/Act/ regulations, etc.) Recommendation for correction action (short and/or long term) based on that reference Person(s) responsible Target/ completion date Status (C, PC, AR) Date of follow-up D O I codes procedure Carbon Monoxide detectors Comments: Communication Item Risk matrix score Verification Reference (e.g., standard/Act/ regulations, etc.) Recommendation for correction action (short and/or long term) based on that reference Person(s) responsible Target/ completion date Status (C, PC, AR) Date of follow-up D O I
communication book OHC bulletin board staff room bulletin boards posting of harassment policy Comments: Other Item Risk matrix score Verification Reference (e.g., standard/Act/ regulations, etc.) Recommendation for correction action (short and/or long term) based on that reference Person(s) responsible Target/ completion date Status (C, PC, AR) Date of follow-up D O I Comments: Item Risk matrix score Verification Reference (e.g., standard/Act/ regulations, etc.) Recommendation for correction action and/or long term) based on that reference Person(s) responsible Target/ completion date Status (C, PC, AR) Date of follow-up D O I Comments: