Supervisors Review Rating Sheet for Safety Performance

(Circle Appropriate Evaluation Points for Performance)

Rating Items: 0 None or N/A; 1 Adequate; 2 Average; 3 Excellent; 4 Distinguished Performance Ratings

1. SAFETY MEETING/ SAFETY TRAINING

Does the supervisor conduct a safety meeting each month for his/her department? 0 1 2 3 4
Does the supervisor attend a department or plant safety meeting each month? 0 1 2 3 4
Does the supervisor attend training programs such as first aid, CPR, forklift, etc.? 0 1 2 3 4
Does the supervisor give new or transferred employees a safety orientation? 0 1 2 3 4

2. SAFETY AND HEALTH INSPECTIONS

Is the supervisor conducting monthly safety/ health inspections? 0 1 2 3 4

Is the proper inspection form being used? 0 1 2 3 4
Are unsafe actions or conditions being corrected as soon as possible? 0 1 2 3 4
Are work orders for corrective action being submitted? 0 1 2 3 4

3. JOB HAZARD ANALYSIS (JHA)

Is one JHA completed each quarter? 0 1 2 3 4

Are employees participating in each JHA? 0 1 2 3 4
Is quality of JHA meeting company standards? 0 1 2 3 4

4. INJURY INVESTIGATION

Are the forms completed and submitted within 24/48 hours? 0 1 2 3 4

Are the forms completely filled out on company form? 0 1 2 3 4
Have recommendations for corrective action been completed? 0 1 2 3 4
For zero injuries, has a simulated report been completed? 0 1 2 3 4

5. INCIDENT/ NON-INJURY REPORTS

Are significant incidents being investigated? 0 1 2 3 4

Is the completed incident form being submitted with a photo? 0 1 2 3 4
Is corrective action taken on each incident? 0 1 2 3 4

6. SUPERVISOR'S SAFETY ATTITUDE

Does the supervisor demonstrate a sincere interest in his/ her employee's safety? 0 1 2 3 4

DATE: Total Scoring: Scoring Key

30-48 Points = Adequate @ 5 % of Review

Name of Supervisor: 49-55 Points = Average @ 10% of Review

56-63 Points = Excellent @ 15 % of Review

Signature of Manager: 64-72 Points = Distinguished @ 20% of Review

Facility:

Overall Point/ Performance Total: