Sample Checklist & Instructions

Gopher State Community and Technical College Labor - Management Safety Committee It is the practice of this institution to conduct an inspection of the safety and health conditions in its work sites at least once each year. This inspection should be completed by the end of the Spring 2002 semester. Corrective actions will be taken to resolve safety problems. Completing and returning this survey promptly will help those doing the inspections to locate problems in your particular location. The people who do the inspections will be using the same form.

Please print out this set of combined instructions and checklist, complete them, and return them to Jane Doe, Box 32, by March 18, 2002. The instructions are simple. Please mark items as being true, false, or not applicable in your location. For any item which you indicate is true, please provide information about the specific problem and its location either in the space to the right of the item on the checklist or on an attached sheet.

Area: _________________________________________

Date: __________________________

Person Completing This Checklist:

____________________________________________