UNIVERSITY LIBRARY/MUSEUM OF ART
JOINT HEALTH AND SAFETY COMMITTEE
WORKPLACE INSPECTION RECORDING SHEET
/Building/Department/Area :
/Date of Inspection:
/Inspector Name(s):
/Supervisor Name(s)
Shaded area to be filled out by responsible supervisor
/INSPECTED: / S-SATISFACTORY/
N-NOT SATISFACTORY / BRIEF DESCRIPTION OF
HAZARD OBSERVED / RECOMMENDED
CORRECTIVE ACTION / REVIEW OF HAZARD & CORRECTIVE ACTION TAKEN / DATE ACTION TAKEN /
FLOORS /
LIGHTING
FLASHLIGHTS
AIR QUALITY
WINDOWS
STAIRWELLS
CORRIDORS
WASHROOMS/
LOUNGES
ELECTRICAL
DEVICES
EQUIPMENT
WORKPLACE
HAZARDS
CHEMICALS
ELEVATORS
FIRST AID BOXES
EMERGENCY TELEPHONES
INSPECTED: / S-SATISFACTORY/
N-NOT SATISFACTORY / BRIEF DESCRIPTION OF
HAZARD OBSERVED / RECOMMENDED
CORRECTIVE ACTION / REVIEW OF HAZARD & CORRECTIVE ACTION TAKEN / DATE ACTION TAKEN
FIRE WARDEN’S VESTS
ERGONOMICS
FIRE SAFETY:
Fire doors
# of extinguishers
Instructions legible
Pressure gauge
Seal intact
Accessibility
Pull stations
Fire exit lights
Instructions to Supervisors:
After completing the shaded areas and signing this report, please return completed form to the co-chairs of the Joint Health and Safety Committee (address listed below) within 3 weeks of the date of inspection.
For high risk hazards marked with an asterisk (*), please take immediate action. Return completed form as soon as possible, but no longer than 1 week from date of inspection. Thank you for your cooperation.
Please forward your completed copy to MML 209, the library office. / Inspector’s Signature: ______
Date: ______/ I have reviewed the hazard(s) noted above, and have recorded the corrective action(s) which have been taken to address these.
Supervisor’s Signature: ______
Date: ______
¨ Corrective action recommended / ¨ Corrective action taken
¨ No corrective action needed / ¨ No corrective action needed