Environmental Engineering Reference
In-Depth Information
tABle 5.1
supervisor safety Performance evaluation Form
monthly or quArterly revIeW suPervIsor sAFety evAluAtIon Form
Supervisor.name:.._______________________________________. Date:.. _______________________
Department:.._________________________________________________________________________
Jobsite:.._____________________________________________________________________________
Supervisor's.supervisor:..________________________________________________________________
Section 1:
______. Number.of.consecutive.days.without.a.reportable.injury:.._______________________________
______. Number.of.irst.aid.cases:..________________________________________________________
______. Number.of.reportable.injuries:..____________________________________________________
______. Number.of.injuries.with.restricted.work.days:..________________________________________
______. Number.of.injuries.with.lost.work.days:.. ____________________________________________
______. Total.number.of.days.away.from.work:.._____________________________________________
Section
2:
Worksite.Evaluation:
______. Housekeeping
______. Workers.wearing.PPE
______. Unsafe.conditions
______. Unsafe.acts
______. Equipment.in.disrepair
______. Faulty.or.defective.tools
______. Safety.devices.or.grounds.removed
Section 3:
Supervisor's.Safety.Performance:
______. Sets.a.good.example
______. Complies.with.OSHA.standards
______. Promptly.corrects.hazards
______. Holds.toolbox.talks.or.safety.meetings
______. Displays.a.safety.attitude
______. Enforces.safety
______. Provides.feedback.to.workers.on.safety.performance
______. Reinforces.safe.work.procedures
______. Recognizes.safe.workers
Score.for.month.or.quarter.._______________________
Gain.(+).or.loss.(-).._____________________________
Ranking.of.the.supervisor.. _______________________
Recommendations:
. 12.. Never.use.or.be.under.the.inluence.of.alcohol,.narcotics,.or.other.drugs.or.
intoxicants.on.the.job.
.
13.. Wear.PPE.as.prescribed.for.each.task.
.
14.. Maintain.order,.as.housekeeping.is.everyone's.responsibility.
.
15.. Observe.“Danger,”.“Warning,”.“Caution,”.and.“No.Smoking”.signs.and.notices.
.
16.. Use.and.handle.equipment,.material,.and.safety.devices.with.care.
