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ThyssenKrupp Elevator Americas

Safety Assessment Form (Field Employee / Jobsite) ThyssenKrupp Elevator Americas Date: Supervisor/Supt.: Employee: Evaluator: Job Name: Safety Item Understands & Follows Process Yes: 3 points Partial: 1-2 points No: 0 points 10 Rules of Health & Safety: These 10 items are 3rd Degree Violations Lockout/Tagout Live Electrical Work / Troubleshooting Jumper Policy Knowledge & Understanding Car Top & Pit Access Fall Protection Mechanical Stored Energy Rigging & Hoisting False Cars & Running Platforms Personal Protective Equipment (PPE) Barricading Reporting Accidents: Recognizes need to report accidents or injuries immediately (within 24 hours) to supervisor Personal Protective Equipment: Recognizes when & where to use Ground Fault Circuit Interrupter, ( electrical equipment, power tools, etc.) Has proper PPE on jobsite at all times (complete Safety Bag) Wears proper eye/face protection whenever work activities are being performed where there is potential for eye/face injury to occur, ( pit, hoistway, machine room, warehouse, construction sites, etc.)

Safety Assessment Form (Field Employee / Jobsite) ThyssenKrupp Elevator Americas Date: Supervisor/Supt.: Employee: Evaluator: Job Name:

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