Number of employees:
Location of employees:
Employees have been educated in company’s injury and illness reporting requirements?
Emergency Phone Numbers Posted?
List types of accidents that could reasonably occur at the workplace:
Corrosive materials are in use at the workplace. Product Name 4-digit or 2-digit ID Number
Have you met industry specific requirements?
First aid supplies are available and location known to all employees?
Designated person to inventory and refill.
Availability of medical personnel to consult on occupational health issues.
Location at mine
Location and availability of emergency services:
Distance from mine:
Est. response time:
Location of medical facilities:
Distance from mine:
Estimated travel time:
For life-threatening injuries, are trained personnel available within four minutes?
Yes
No
For serious injuries, can trained personnel arrive within 15 minutes?
Yes
No
Local emergency services phone pumber are posted near applicable telephones?
Yes
No
Designated Trained First Aid Responder(s)
First Aid Kits are located at:
Eye wash station is located at:
Fire extinguishers are located at:
Location of MSDS’s (Material Safety Data Sheets):
Level of Training
Workplace Location
Contact by:
