Confidential Company Name
Location: A000001-Confidential Location Name

Revised Safety Worksheet (98 out of 128 points or 76% in Compliance) Surveyed On 03/06/2006

AREA 1	Emergency Exits (13 of 17 points)
A.	Are exit signs illuminated “glow in the dark”? (3  points)
1) Yes		SUSTAIN				( 3  )
2) No  		REQUIRES IMMEDIATE ATTENTION	(     )

B.	Is access to exits, pathways to exits, and exit discharges unblocked and unrestricted? (3  points)
1) Yes		SUSTAIN				( 3  )
2) No  		REQUIRES IMMEDIATE ATTENTION	(     )

C.	Are exits unlocked / NOT bolted closed from the inside during occupancy? (4  points)
1) Yes		SUSTAIN				( 4  )
2) No  		REQUIRES IMMEDIATE ATTENTION	(     )

D.	Are emergency evacuation plans posted in the front end and pharmacy? (4  points)
1) Yes		SUSTAIN				(     )
2) No  		REQUIRES IMMEDIATE ATTENTION	( X )

E.	Are NOT AN EXIT signs posted on doors that are NOT exits? (3  points)
1) Yes		SUSTAIN				( 3  )
2) No  		REQUIRES IMMEDIATE ATTENTION	(     )

AREA 2	Fire Extinguishers (16 of 16 points)
A.	Are fire extinguisher stations clearly identified? (3  points)
1) Yes		SUSTAIN				( 3  )
2) No  		REQUIRES IMMEDIATE ATTENTION	(     )

B.	Are fire extinguishers easily accessible (never blocked with merchandise, boxes, carts, etc.)? (3  points)
1) Yes		SUSTAIN				( 3  )
2) No  		REQUIRES IMMEDIATE ATTENTION	(     )

C.	Are fire extinguishers mounted (never on the floor)? (3  points)
1) Yes		SUSTAIN				( 3  )
2) No  		REQUIRES IMMEDIATE ATTENTION	(     )

D.	Are fire extinguishers fully charged with periodic test dates and monthly visual inspection verification on extinguishers’ tag? (3  points)
1) Yes		SUSTAIN				( 3  )
2) No  		REQUIRES IMMEDIATE ATTENTION	(     )

E.	Have associates been trained to use a fire extinguisher? (4  points)
1) Yes		SUSTAIN				( 4  )
2) No  		REQUIRES IMMEDIATE ATTENTION	(     )

AREA 3	Store Sales Floor (11 of 13 points)
A.	Is the store free of trip and slip hazards such as debris, garbage, ice / snow, spills, etc? (2  points)
1) Yes		SUSTAIN				( 2  )
2) No  		REQUIRES IMMEDIATE ATTENTION	(     )

B.	Is there a minimum 36 inch path of travel in all aisles and in all pathways to exits? (3  points)
1) Yes		SUSTAIN				( 3  )
2) No  		REQUIRES IMMEDIATE ATTENTION	(     )

C.	Are stairs clear of obstructions such as debris, garbage, boxes, merchandise, hand carts, totes, etc.? (2  points)
1) Yes		SUSTAIN				( 2  )
2) No  		REQUIRES IMMEDIATE ATTENTION	(     )

D.	Is helium tank(s) secured / chained to the wall? (2  points)
1) Yes		SUSTAIN				( 2  )
2) No  		REQUIRES IMMEDIATE ATTENTION	(     )

E.	Is sales floor merchandise stacked / placed safely? (2  points)
1) Yes		SUSTAIN				( 2  )
2) No  		REQUIRES IMMEDIATE ATTENTION	(     )

F.	Review Store Manager Tour Sheet for the past five days.  Is one complete for each day? (1  points)
1) Yes		SUSTAIN				(     )
2) No  		REQUIRES IMMEDIATE ATTENTION	( X )

G.	Review District Manager Store Visit Sheet.  Is there one filed for the present or previous month? (1  points)
1) Yes		SUSTAIN				(     )
2) No  		REQUIRES IMMEDIATE ATTENTION	( X )

AREA 4	Stock Room (18 of 28 points)
A.	Are exits unobstructed? (4  points)
1) Yes		SUSTAIN				( 4  )
2) No  		REQUIRES IMMEDIATE ATTENTION	(     )

B.	Is a minimum 36 inch clearance maintained from electrical breaker panels? (4  points)
1) Yes		SUSTAIN				( 4  )
2) No  		REQUIRES IMMEDIATE ATTENTION	(     )

C.	Is merchandise arranged in a stable manner? (2  points)
1) Yes		SUSTAIN				( 2  )
2) No  		REQUIRES IMMEDIATE ATTENTION	(     )

D.	Is there an 18 inch clearance between the merchandise and the light fixtures and sprinklers? (2  points)
1) Yes		SUSTAIN				( 2  )
2) No  		REQUIRES IMMEDIATE ATTENTION	(     )

E.	Are ladders in good condition? (3  points)
1) Yes		SUSTAIN				( 3  )
2) No  		REQUIRES IMMEDIATE ATTENTION	(     )

F.	Are ladders secured to the wall when not in use? (3  points)
1) Yes		SUSTAIN				(     )
2) No  		REQUIRES IMMEDIATE ATTENTION	( X )

G.	Are compactor and baler safety guards unrestricted and in place? (3  points)
1) Yes		SUSTAIN				( 3  )
2) No  		REQUIRES IMMEDIATE ATTENTION	(     )

H.	Are “No Smoking” signs posted in the stock room and basement? (3  points)
1) Yes		SUSTAIN				(     )
2) No  		REQUIRES IMMEDIATE ATTENTION	( X )

I.	Are emergency evacuation plans posted in the stock room and basement? (4  points)
1) Yes		SUSTAIN				(     )
2) No  		REQUIRES IMMEDIATE ATTENTION	( X )

AREA 5	Safety Compliance Monthly Training Documents (6 of 12 points)
A.	Are monthly safety meeting verification forms from the past six months located in the Retail Safety program section of the Store Operations Manual? (3  points)
1) Yes		SUSTAIN				(     )
2) No  		REQUIRES IMMEDIATE ATTENTION	( X )

B.	Have all store associates signed the monthly safety meeting verification forms? (3  points)
1) Yes		SUSTAIN				( 3  )
2) No  		REQUIRES IMMEDIATE ATTENTION	(     )

C.	Has the Store Manager signed and dated each completed monthly safety meeting verification form? (3  points)
1) Yes		SUSTAIN				( 3  )
2) No  		REQUIRES IMMEDIATE ATTENTION	(     )

D.	Has the Store Manager signed and dated each completed monthly Life Safety Checklist? (3  points)
1) Yes		SUSTAIN				(     )
2) No  		REQUIRES IMMEDIATE ATTENTION	( X )

AREA 6	One Hour Photo Lab (22 of 30 points)
A.	Is the photo lab clean and neat (no food; no accumulated paper, rags, etc)? (3  points)
1) Yes		SUSTAIN				( 3  )
2) No  		REQUIRES IMMEDIATE ATTENTION	(     )

B.	Is the portable eyewash bottle in the photo lab and is the solution in date (not expired)? (4  points)
1) Yes		SUSTAIN				( 4  )
2) No  		REQUIRES IMMEDIATE ATTENTION	(     )

C.	Are splash goggles available in the photo lab? (3  points)
1) Yes		SUSTAIN				( 3  )
2) No  		REQUIRES IMMEDIATE ATTENTION	(     )

D.	Are Neoprene rubber gloves available in the photo lab? (3  points)
1) Yes		SUSTAIN				( 3  )
2) No  		REQUIRES IMMEDIATE ATTENTION	(     )

E.	Is a vinyl apron available in the photo lab? (3  points)
1) Yes		SUSTAIN				( 3  )
2) No  		REQUIRES IMMEDIATE ATTENTION	(     )

F.	Is the Health, Safety & Environmental (HSE) Manager’s Guide binder in the Manager’s office? (3  points)
1) Yes		SUSTAIN				( 3  )
2) No  		REQUIRES IMMEDIATE ATTENTION	(     )

G.	Is the Health, Safety & Environmental (HSE) Material Safety Sheet / MSDS binder kept in the photo lab? (3  points)
1) Yes		SUSTAIN				( 3  )
2) No  		REQUIRES IMMEDIATE ATTENTION	(     )

H.	Have all photo lab associates completed initial new hire as well as subsequent annual training and signed training verification forms, which are maintained in the “Training Records” section of the Manager’s Guide binder? (4  points)
1) Yes		SUSTAIN				(     )
2) No  		REQUIRES IMMEDIATE ATTENTION	( X )

I.	Has the Store Manager completed and signed the verification of Manager Responsibilities for the HSE program, which is maintained in the “Training Records” section of the Manager’s Guide? (4  points)
1) Yes		SUSTAIN				(     )
2) No  		REQUIRES IMMEDIATE ATTENTION	( X )

AREA 7	Workers' Compensation (12 of 12 points)
A.	Is the Workers' Compensation Physician Panel posted in the associates' breakroom? (3  points)
1) Yes		SUSTAIN				( 3  )
2) No  		REQUIRES IMMEDIATE ATTENTION	(     )

B.	Have there been no associate accidents / injuries over the past 30 days? (3  points)
1) 0		SUSTAIN				( 3  )
2) > 0 		REQUIRES IMMEDIATE ATTENTION	(     )

C.	Is a completed copy of the ACCIDENT e-form maintained in the ACCIDENT e-form File, which is located in the personnel file cabinet, for each reported work injury?  (If there have been no work injuries, choose “Sustain.”) (2  points)
1) 0		SUSTAIN				( 2  )
2) > 0 		REQUIRES IMMEDIATE ATTENTION	(     )

D.	Has the Store Manager completed a post accident investigation for each reported work injury? If there have been no work injuries, choose “Sustain.” (1  points)
1) Yes		SUSTAIN				( 1  )
2) No  		REQUIRES IMMEDIATE ATTENTION	(     )

E.	Is the Store Manager familiar with the Temporary Transitional Duty Guidelines located in the Workers' Compensation Chapter of the Retail Safety Program? (1  points)
1) Yes		SUSTAIN				( 1  )
2) No  		REQUIRES IMMEDIATE ATTENTION	(     )

F.	Does the Store Manager adhere to the Temporary Transitional Duty Guidelines? (1  points)
1) Yes		SUSTAIN				( 1  )
2) No  		REQUIRES IMMEDIATE ATTENTION	(     )

G.	Does the Store Manager maintain adequate contact with the worker's compensation claim office or third party administrator (TPA) to review open claims.  Review Retail Safety Program pp. 42-49?  If there have been no worker' compensation claims, choose “Sustain.“ (1  points)
1) Yes		SUSTAIN				( 1  )
2) No  		REQUIRES IMMEDIATE ATTENTION	(     )

Area 1D & 4I - Evacuation Plans Must Be Posted
 In Front End, Pharmacy, And Stockroom.
Area 3F - Correct Store Tour Sheet Must Be Fully Utilized And
Loggedmonthly In Management Guide.
Please Relpy To Dma And Myself When All
Items Are Completed.

Entered: 28-Mar-2006 17:24 	By: JCG