Page 61 - SAMA HSE PLAN

Sama Global HSE Plan December 2023

Appendix 3. Sample Employee Safety Checklist

Employee Name: Date:

Job Name: Job Number:

Superintendent:

Basic Safety:
( ) Personal Information
( ) Company's Safety Policy
( ) Safety Representative
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Protective Equipment
( ) Eye Protection ‐ equipment issued ___yes ___no
( ) Work Shoes
( ) Head Protection ‐ Hard Hat
( ) Any additional special department equipment ‐ equipment issued _yes __no

Accidents
( ) Does employee understand WHY we want them to report the injury?
( ) Explain that he/she must record the accident by Informing the Superintendent or Foreman IMMEDIATELY
( ) Immediately meaning at or near the time of injury and on the same day of the injury).
( ) Explain that failure to report accidents immediately is a violation of Safety Policy and may be subject to

immediate termination.
( ) Employee understands CLEARLY what he/she is to do immediately if injured, no matter how slight

Employee Responsibilities to Co‐Workers
( ) Explain how employees own personal safety and that of fellow workers, depends on them.

Explanation of General and Departmental Safety Rules
( ) Explained safety rules and the use of safety violations
( ) Encourage employee to ask questions.

Proper Job Instruction
( ) Showed employee the safe, correct and easiest way to do job.
( ) Actually illustrated methods and questioned employee on understanding.
( ) Briefed employee on proper lifting techniques
( ) Written hazard communications programs and explain to employees.
( ) Material safety data sheets (M.S.D.S.) and explain b employee.

I state that I have attended the safety orientation, have read, and received a copy of the safety rules and
regulations.

I further state that I understand these rules and acknowledge that compliance to safety rules and regulations is a
condition of employment.

EMPLOYEE SIGNATURE ___________________ DATE _____________

SUPERVISOR'S SIGNATURE: ___________________ DATE ______________
APPROVED BY SUPERINTENDENT:.______________ DATE ______________

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