(The "Xyz Company" name depicted below will be replaced with YOUR Company/Business name in black print in the manual) Xyz Company Safety and Health Policy Statement . We are dedicated to providing a safe and healthful environment for employees and customers, protecting the public, and preserving Xyz Company assets and property. . At Xyz Company, our most valuable resource are the people who work for us. Injuries can be prevented. To achieve this objective, Xyz Company will make all reasonable efforts to comply with all government regulations pertaining to safety and health issues. An effective Safety and Health Program will be carried out throughout our organization. . The Safety and Health Program will assist management and non-supervisory employees in controlling hazards and risks which will minimize employee and customer injuries, damage to customer's property and damage or destruction of Xyz Company property. . All employees will follow this program. This program is designed to encourage all employees to promote the safety of their fellow employees and customers. To accomplish our safety and health goals, all members of management are responsible and accountable for implementing this policy, and to insure it is followed. . Xyz Company is sincerely interested in our employee's safety. The policy of Xyz Company is to provide safe equipment, adequate tools and training, and the necessary protective equipment. It is the employee's responsibility to follow the rules of safety as established for their protection and the protection of others, and to use the protective devices, which Xyz Company provides. . 1

Remember, you can change the below checklist to suit your needs before you print it up...

Safety Inspection Checklist Inspected By: _____________________________________ Date: _________ -----------------------------------------------------......----------.......................--(Mark N/A as appropriate) 1. WORK SITE INFORMATION: a. Posting OSHA and other work site warning posters _____ b. Are Safety Meetings conducted periodically? ....................................................When was the last Meeting? _____ __________ c. First aid equipment properly stocked and accessible? _____ d. Are work site injury records being kept? _____ e. Are emergency telephone numbers conspicuously posted? _____ f. Is the EMERGENCY INFORMATION form posted (Page 8)? _____ Describe Violation - Location - Remedy Taken ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ 2. HOUSEKEEPING AND SANITATION : a. Are emergency lights fully operational? mmmmmmm _____ b. General neatness of working areas _____ c. Regular disposal of waste and trash _____ d. Passageways and walkways clear _____ e. Waste containers provided and used - _____ f. Sanitary facilities adequate and clean _____ g. Adequate supply of water _____ h. Adequate lighting- _____ i. Trash receptacle for drinking cups _____ j. Are handrails and stair treads in good repair? _____ k. Is smoking restricted to certain locations? _____ l. Are electrical cords and plugs in good condition? _____ m. Are electric circuit breakers free of obstructions? _____ Describe Violation - Location - Remedy Taken ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ 14