Workplace Safety Assessment Form
Please complete this form to help us evaluate the safety conditions in your workplace.
Your Full Name
First Name
Last Name
Date of Assessment
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Department or Area Assessed
Rate the overall safety of the workplace
1
2
3
4
5
Are there any immediate hazards present?
Yes
No
If yes, please describe the hazards
Safety equipment available (check all that apply)
Additional comments or suggestions
Submit
Should be Empty: