sample

1. TIME From To
1
2
Green Orange Red
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
1.10
1.11
2.1
2.2
2.3
2.4
2.5
2.6
Emergency preparedness management
Individual OSH performance measurements
Record keeping
Page 1 of 5
Consistent disciplinary procedure for OSH violators
Commitment and follow-up actions
1.0 TOP MANAGEMENT PHILOSOPHY AND COMMITMENT
Two-way communications between top management
and employee
DATE
NAME OF AUDITORS
Response to citation
Recognition system for outstanding section and/or
individual (if any)
General OSH awareness
OSH organizational structure
2.0 ORGANIZATIONAL STRUCTURE AND RESOURCES
Budget for OSH activities
Training need analysis and training plan
Specific and clear OSH responsibilities and
accountability for all levels of management
Motivated management and employees
Company OSH policies
Company OSH goals and measurements
Comment
SIGNATURE
Audited items ( verification of documentation, interviews, plant
tour )
COMPANY &
ADDRESS
AUDIT CHECKLIST
Understanding and compliance of legislation
TOTAL SCORE
SAFETY & HEALTH
MANAGEMENT PLAN
NAGANO BUILDER PROJECT SAFETY PLAN

2. Green Orange Red
3.1
3.2
3.3
4.1
4.2
4.3
4.3
4.4
5.1
5.2
5.3
5.4
5.5
6.1
6.2
6.3
6.4
6.5
6.6
6.7
6.8
6.9
6.10
6.11
6.12
TOTAL SCORE
Regular inspections
Adequate machine guarding for all equipment and
machines
Audited items ( verification of documentation, interviews, plant
tour )
Adequate disciplinary action for violators
Adequate training for all employees
Validation of site permit
Update and availability of applicable legislation, codes
of practice (CP) and relevant Malaysia Standards
AUDIT CHECKLIST
Adequate control for contractors working on electrical
supplies
Validation of applicable electrical licenses and permits
Adequate warning signs for high and low tension power
supplies
Adequate identification for authorized electricians or
contractors
Applicable permit for corrosive, poisonous storage tanks
/ vessels
Adequate warning signs
Adequate fall protection
Restricted area control
Secondary containment for such tanks/vessels
Adequate walkway, passage-way
Safe construction of handrails
Conditions for mobile and fixed ladders
Slip, over-head, fall and/or trip hazards
Safe and sound materials storage/stacking
6.0 PROVISION FOR A SAFE WORKPLACE
4.0 MACHINE GUARDING COMPLIANCE
Page 2 of 5
Regular inspections
Restricted area control
Appropriate OSH training for new and existing
employees
Comment
3.0 UPDATE OF APPLICABLE PERMITS & LEGISLATION
5.0 ELECTRICAL SAFETY COMPLIANCE
OSH inspections and records
NAGANO BUILDER PROJECT SAFETY PLAN
Easy access to applicable permits and legislation
SAFETY & HEALTH
MANAGEMENT PLAN

3. Green Orange Red
7.1
7.2
7.3
7.4
7.5
7.6
7.7
7.8
7.9
8.1
8.2
8.3
8.4
8.5
8.6
8.7.
8.8
9.1
9.2
9.3
9.4
9.5
9.6
9.7
Audited items ( verification of documentation, interviews, plant
tour )
TOTAL SCORE
Permit-to-work system
Authorized entrants, standby attendants and site
supervisor
Comment
Restricted area control
Adequate written procedure and its enforcement
Confined space training for authorized employees and
or contractors
Personal protective equipment
Site supervision and air monitoring records
Disciplinary procedure for violators
Adequate warning signs
7.0 WORK IN CONFINED SPACE
Fire fighting and protection equipment, such as
sprinklers, fire extinguishers, hose-reels, etc.
Flammable substances control & storage
Means of escape (free from obstructions)
8.0 FIRE PREVENTION
Adequate signs for exits and fire fighting equipment
Housekeeping
Inspections, testing and drill records
Written emergency evacuation plan
Adequate training for all employees
Register for hoists, lift, lifting gears and appliances
9.0 LIFTING EQUIPMENT
Permits for these equipment
Stencils for safe working load limit
Restricted area control
Preventive maintenance, testing, inspection records
Written operating procedures
Adequate training for all employees
Page 3 of 5
AUDIT CHECKLIST
SAFETY & HEALTH
MANAGEMENT PLAN
NAGANO BUILDER PROJECT SAFETY PLAN

4. Green Orange Red
10.1
10.2
10.3
10.4
11.1
11.2
11.3
11.4
11.5
11.6
11.7
11.8
11.9
1.10
11.1
11.1
12.1
12.2
12.3
12.4
12.5
Communication channels
Audited items ( verification of documentation, interviews, plant
tour )
AUDIT CHECKLIST
Register of PPE recipients
Hazard assessment
10.0 PERSONAL PROTECTIVE EQUIPMENT (PPE)
Written purchasing and operating procedures
Adequate training for all employees
Written operating and emergency procedures
Disciplinary procedure for violators
11.0 CHEMICAL SAFETY DATA SHEET
Ventilation
Personal protective equipment
Restricted area control
Medical surveillance
Applicable permit for corrosive, poisonous storage
Notification to authorities
Preventive maintenance and inspection records
Availability of specific permit/license
Investigation and follow-up actions
12.0 REPORTING OF ACCIDENTS
Written procedure
Risk/hazard assessment and records
TOTAL SCORE
Page 4 of 5
Adequate training for all employees
Comment
Access to CSDS
Warning signs
SAFETY & HEALTH
MANAGEMENT PLAN
NAGANO BUILDER PROJECT SAFETY PLAN

5. Green Orange Red
13.1
13.2
13.4
13.5
13.6
13.7
13.8
13.9
13.10
13.11
13.12
13.13
13.14
SCORE
5
3
0
A
B
C
D
E
Air, water, soil monitoring and testing
Restricted area control
Warning signs
TOTAL SCORE
Ventilation
Drainage
Medical surveillance
Lighting
Overcrowding
Sanitary
Noise and vibration
Written procedure
GENERAL COMMENT
The contractor has shown full compliance and commitment towards safety and health issues at
site. They should maintain and improve further on certain aspects as shown in the "Orange"
column.
AUDIT RATING
COLOR
Cleanliness
GOOD
SATISFACTORY
AUDIT OVERALL SCORE
VERY GOOD
AUDIT GRADING
GREEN
ORANGE
EXCELLENT
AUDITED ELEMENTS DO NOT FULLY COMPLY WITH IN-HOUSE OSHMS
AUDITED ELEMENTS DO NOT COMPLY WITH IN-HOUSE OSHMS
AUDIT GRADING
OVERALL SCORE
RED
First aid facilities
Page 5 of 5
13.0 OCCUPATIONAL HEALTH AND WELFARE
UNSATISFACTORY
>90%
75% - 90%
50% - 75%
35% - 50%
< 35%
AUDITED ELEMENTS COMPLY WITH IN-HOUSE OSHMS
LEVEL OF SAFETY ACHIEVED
Audited items ( verification of documentation, interviews, plant
tour )
Comment
AUDIT CHECKLIST
SAFETY & HEALTH
MANAGEMENT PLAN
NAGANO BUILDER PROJECT SAFETY PLAN