Form # HSSE-F-038

HSSE INSPECTION FORM Revision No: 0

Release Date: 3RD June, 2021

Name of Supervisor/Manager: ___________________________ Location: _________________

Date: ____________________ Inspection Number: _________

ELECTRICAL YES NO Action Required? Action by

Is there evidence of worn or damage to □ □ When?
electrical cords/Power tools?
□ □
Are outlets in good working condition?

FIRE YES NO
Does the equipment present any inherent □ □
fire hazards such as open flames, flammable
liquids, solids and gases, etc.?

Are these hazards properly controlled by

□ □
safeguards built into the equipment or
provided outside, over, and around the
equipment?

Are flammables chemical away from heat □ □

sources?
SLIPS, TRIPS AND FALLS

Are there evidence of slip, trips and fall □ □

hazards?

Are there trailing cables around the

compound and in the main office? □ □

Are there tools and material left lying in the

□ □
walkways?

PERSONAL PROTECTIVE
EQUIPMENT (PPE)

Are employees wearing with suitable PPE □ □

for their jobs?
 Form # HSSE-F-038

HSSE INSPECTION FORM Revision No: 0

Release Date: 3RD June, 2021

Has Appropriate PPE been provided for the □ □

task at hand?

Is the PPE provided in good condition and □ □

free of defects?

FALL FROM HEIGHTS

Are there equipment and materials stored at □ □

heights that can result in a falling hazard?

Are materials and equipment that are stored □ □

at heights properly secured?

HOUSE KEEPING

Are there bins provided for employees to □ □

dispose of consumables used?

Are these bins emptied on a regular basis to □ □

prevent spillage?

CHEMICALS

Are chemicals appropriately stored and □ □

away from sources of ignition?

Are MSDS sheets stored in a suitable place □ □

and are accessible to users?

Is there a suitable Bund to capture chemical □ □

spills?

Is the bund clean and free of debris?

□ □
EMERGENCY PROCEDURES

Have employees been trained in emergency □ □

procedures and are aware of their Muster
Points, Fire Wardens etc and roles in the
event of an emergency?
 Form # HSSE-F-038

HSSE INSPECTION FORM Revision No: 0

Release Date: 3RD June, 2021

Does the placement of the equipment □ □

present any evacuation hazards in the event
of a serious equipment malfunction?
WELFARE

Is there a supply of wholesome drinking

water for workers? □ □

Are there comfortable seating arrangement □ □

for workers to use during lunch or break
periods?

Is the temperature suitable in the lunch room

□ □
and offices?

Is there a facility to heat and cold food or □ □

drink?

GENERAL OBSERVATION

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SIGNATURE DATE

__________________________ _______________________