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Safety Gemba Walk Template

A Safety Gemba Walk Template is a useful tool for workplace safety inspectors to check the safety of a workplace. The purpose of the Safety Gemba Walk Template is to identify potential hazards, assess current safety measures and make recommendations for improvement.

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PPE & Safe Work Practices
Correct PPE worn and is it in good condition?
Metatarsal safety shoes worn and are they in good condition
Hearing protection worn
Gloves (if required)
Other required PPE?
Lifting Devices
Material lifting devices used and are they in good condition
Can operator explain daily inspection performed on lifting devices
Inspect lifting devices for worn or damaged devices
Are suspended loads attended
Suspended loads must never be lifted over employees
Safety Shower / Eye Wash Station
Is their a shower of eye station located where acids / bases (corrosives) used. " Sodium Aluminate"
Are they inspected monthly and access not blocked
Are eye wash stations available in high dust areas
Emergency Exits
Aisles and emergency exits not blocked
Is voltage indicated on electrical control enclosures, power cabinets,, junction boxes etc.
Arc Flash label present on electrical control enclosures, power cabinets, junction boxes etc.
Clearance in front of electrical enclosures 36" (0-150v) and 42" (151-600v)
Chords are free from frays and damage
Extension cords only allowed for temporary situations
GFCI's required on portable electric tools and in areas where wetness or damage to cord is possible
Are knockout plugs present on all electrical enclosures
Mobile Equipment
Are inspections being completed on equipment, prior to being used before each shift
Mobile equipment license and training current within 3 years
Seatbelt used whenever forklift operated
Material Storage Area
Material organized and rotated by date
Material not triple stacked, only two high
Flammable Cabinets
Only flammable liquids in cabinet (no paper, wood or plastic stored in cabinet)
Cabinets undamaged
No more than 3 cabinets within 100 square feet
Are all areas free from spills?
Machine Guarding
Is point of operation (grinding wheel, etc.) protected such that inadvertent contact is prevented?
Flywheels, gears, shafts, pulleys, belts, gears, sprockets, chains and couplings guarded to protect employees
E-stop button present
Walking / Working surfaces
Are the walkways clear and free of debris
Are all holes or floor openings guarded?
Fire Extinguishers
Monthly Inspection completed / Verify completely charged
Confined space
Marked with proper signage (permit required sign or non permit required sign
All containers labeled. (Original container with Manufacturers Label or secondary container with HMIS label)
Do employees know how to access an MSDS for a chemicals used?
Lockout / Tagout
Is machine specific energy control procedure present?
Are LOTO labels present
Compressed Air Nozzles
Are nozzles labeled as OSHA compliant. (regulate air pressure to 30psi or less)
Compressed Gas Cylinder Storage
Are cylinders identified with a durable label that clearly identifies the cylinder contents and gives a brief description of the potential hazard?
Cylinders secured with chain, lab strap or hard stock device located on the upper one third of the cylinder
Nesting methods for storage are prohibited. Acceptable means of storage include individual chains or straps, holding racks, cylinder carts etc.
Flammable gasses shall be stored at least 20 feet from oxidizers and any other source of ignition or separated by an approved firewall
OE and Standard Work
Material consumption be tracked PP/T?
Are 5S audits and Safety audits posted and current
Observe if standard work is being followed
Area clean & organized (less than 1 day of dirt)?
Aisles and emergency exits not blocked?
Do the employees know: (Interview a few people)
How to report suggestions
Who to report incident or injuries to and how long they have to do it in "as soon as it happens"
How to do and R3 and what it is
What is standard work and where is it located
What do they do if they find a problem
What a STOP card is and do they have them available
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Creating a Safer Workplace: How to Use a Gemba Walk Template

The Safety Gemba Walk Template can be used to ensure that the workplace is safe and compliant with any applicable safety regulations of your business. The template typically includes sections for assessing the physical environment of the workplace, evaluating the safety equipment, and documenting any safety issues or safety concerns that have been identified. It can also include sections for interviewing personnel, documenting safety training and reviewing safety policies.

Lumiform’s customizable template can be used to evaluate a variety of different work environments and be tailored to the specific needs of the workplace. Gemba walks are an effective way of monitoring and assessing safety risks in the workplace and bringing them to the attention of management. A safety gemba walk template gives organizations the ability to create a structured process for conducting a safety gemba walk, as well as providing an organized and consistent structure for collecting and reporting safety data.

Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.
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