Version 5
January 2009
1
NC State University
Supervisor’s Safety Self Assessment Checklist
This checklist is a tool to aid the supervisor and his/her employees in identifying those activities and
conditions that need attention to achieve and maintain a safe work environment. This format was
developed by the CALS Safety Committee (our thanks!) from the original EH&S checklist and has
been adopted for University use.
Completion of this assessment fulfills the annual requirement for an inspection or self assessment as
specified on the certification page of the Safety Plan. During the assessment process, note
comments and reminders in the Comment or Corrective Action Needed column as necessary. When
the appropriate action has been taken, note this in the Date Completed column.
Keep this checklist with your safety plan. It will allow for quick reference to identify actions not
completed and will serve as an educational tool and useful reference for both staff and students.
Contact Ken_Kretchman@ncsu.edu with any questions or suggestions regarding this checklist.
College
Department
Building
Room(s)
Person Performing Inspection
Responsible Supervisor or Faculty Member
Signature
Inspection Date
Version 5
January 2009
2
NC State University Safety Self Assessment Checklist
Safety Self Assessment Checklist
Table of Contents
A. Overview of Supervisor Safety Responsibilities for their Employees
B. General Housekeeping and Facility Maintenance
C. Medical Surveillance, First Aid and Medical Emergencies
D. Electrical Safety for Office, Laboratory and Field Employees
E. Hazardous Equipment and Processes
F. General Work activities covered by Specific OSHA Standards
G. Chemical Use
H. Waste Disposal
I. Compressed Gases
J. Safety Showers and Eyewashes
K. Radiation Producing Equipment and Radioactive Materials
L. Biologica