Evaluation Summary Company Auditor Date Section Possible Actual Minimum Section Title Auditor Comments Points Standard Number Points 1 Health and Safety Policy 27 14 2 Hazard Assessment, Analysis and Control 42 21 17 9 3 Safe Work Practices 4 Safe Job Procedures 15 8 5 Company 9 5 21 11 6 Personal Protective Equipment (PPE) 7 Preventative Maintenance Program 12 6 8 Training and Communication 42 21 9 Inspections 30 15 10 Investigations and Reporting 30 15 11 Emergency Preparedness 27 14 12 Statistics and Records 18 9 13 Legislation 12 6 Total 302 Minimum standard = 80% overall and 50% minimum in SCSA Supplemental Section each of sections 1 through 13. Possible Actual Standard Section # Section Name Points Points Achieved % Actual Points X 100 = Yes No Possible Points SS1 Physical Conditions 18 No Standard Achieved Yes SS2 Harassment Policy 8 SS3 Committees / Representative 12 Auditor Signature Auditor Comments Senior Company Officer Name SS1 Senior Company Officer Signature SS2
Evaluation Summary Company Auditor Date Section Number Section Title Possible Points Actual Points Minimum Standard Auditor Comments 1 Health and Safety Policy 27 14 2 Hazard Assessment, Analysis and Control 42 21 3 Safe Work Practices 17 9 4 Safe Job Procedures 15 8 5 Company 9 5 6 Personal Protective Equipment (PPE) 21 11 7 Preventative Maintenance Program 12 6 8 Training and Communication 42 21 9 Inspections 30 15 10 Investigations and Reporting 30 15 11 Emergency Preparedness 27 14 12 Statistics and Records 18 9 13 Legislation 12 6 Total 302 Minimum standard = 80% overall and 50% minimum in each of sections 1 through 13. SCSA Supplemental Section Actual Points X 100 = Possible Points Standard Achieved % Yes No Section # Section Name Possible Points Actual Points Standard Achieved SS1 Physical Conditions 18 Yes No SS2 Harassment Policy 8 Auditor Signature SS3 Committees / Representative 12 Auditor Comments Senior Company Officer Name SS1 Senior Company Officer Signature SS2
SELF_AUDIT_v3.0_02-May-17.docx