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This document prints out on most jet or laser printers as you see it. You may also use your cursor to highlight (windows Ctrl a) the text, copy (windows Ctrl c) and paste (windows Ctrl v) this document into your favorite word processor. Then change it to suit your requirements. OSHA Checklist and ReportCompany representatives must complete this form during each OSHA inspection. Additional pages, photographs, and other documents should be attached when needed to complete any question.
1. Company representative: __________________________________________________
Name
2. Date of inspection: _______________________________________________________
3. OSHA inspector: _______________________________________________________
Name and Title
4. OSHA Area Director: _____________________________________________________
Telephone Number (OSHA): _______________________________________________
OSHA Address: _________________________________________________________
5. Reason for inspection:_____________________________________________________
______________________________________________________________________________
A. If the inspection is the result of an employee complaint:
Describe the nature of the complaint (e.g., identify the machine,
equipment, or condition which forms the basis of the complaint):
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Date OSHA received the complaint: ___________________________________
Was the complaint verified? When? _____________________________
Did OSHA verify that the complainant was in fact an employee? How was this
done? When?
__________________________________________________________________
__________________________________________________________________
Assuming that the condition described in the complaint exists, what
regulation does the OSHA inspector maintain has been violated?
__________________________________________________________________
__________________________________________________________________
Set forth any errors or inaccuracies in the complaint.
__________________________________________________________________
__________________________________________________________________
B. If the inspection is the result of a workplace fatality or accident:
Describe in detail the circumstances surrounding the incident, including
names of witnesses.
__________________________________________________________________
__________________________________________________________________
Attach a copy of the telegram sent to OSHA within 8 hours of the fatality.
C. If the inspection is a follow-up inspection:
Identify the previous citation, proposed penalty, and abatement
requirement, if any:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Attach a copy of the earlier citation and the OSHA inspector's worksheets
relating to the citation, if available.
D. If the inspection is a general scheduled inspection pursuant to a neutral
administrative or legislative plan:
Describe the inspection program and the criteria used to select this
particular facility for inspection:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Were the company injury and illness logs checked prior to the inspection?
_________________________________________________________________
Was the company's lost-time injury rate below the national average for
manufacturing?
__________________________________________________________________
6. Is this an inspection of a multi-employer worksite? __________________________
If so, list the names of all other employers and the number of workers employed
by each employer who are present on the worksite, with a brief description of
the nature of the work being performed.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
7. If no search warrant was presented, did you consent to a limited inspection?
A. If so, did you read a statement of limited consent to the OSHA inspector
and provide him with a copy of the letter?
________________________________________________________________________
Time and date statement read: ______________________________________________
Was a confirmation letter sent to the OSHA Area Director?
________________________________________________________________________
B. Describe the specific machine, equipment, or condition you permitted
the OSHA inspector to inspect.
________________________________________________________________________
________________________________________________________________________
Attach a copy of the letter of limited consent mailed to the Area Director.
C. Did the OSHA inspector attempt to broaden the scope of the inspection
after being admitted for the purpose of making a limited inspection?
________________________________________________________________________
If so, describe the machines, equipment or conditions which you refused
to allow the OSHA inspector to inspect:
________________________________________________________________________
________________________________________________________________________
8. If no search warrant was presented, was the OSHA inspector refused entry?_______
A. If so, was the statement read (and a copy of the statement given)
to the OSHA inspector explaining the company's position?
________________________________________________________________________
Time and date statement read: ________________________________________
B. Was a confirmation letter sent to the OSHA Area Director explaining the
company's position?
________________________________________________________________________
Time and date of letter: ______________________________________________
9. Did the OSHA inspector present a search warrant upon arrival?
________________________________________________________________________
A. If so, describe the contents of the search warrant and the specific
machine, equipment, or condition to be inspected:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Attach a copy of the search warrant.
B. If the inspector was permitted to inspect pursuant to the warrant, was
a copy of a letter of protest addressed to the Area Director handed to
the OSHA compliance officer?
________________________________________________________________________
Time and date letter was given to compliance officer:
________________________________________________________________________
Was a certified copy mailed to the Area Director, return
receipt requested?
________________________________________________________________________
Attach a copy of the letter of protest mailed to the Area Director.
10. List any records, documents, or notices reviewed by the OSHA inspector:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
11. Describe in detail any remarks made during the opening conference, including
any statements made to the OSHA inspector regarding the scope of the inspection,
trade secrets, or any other matter of significance:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
12. List all machines, equipment, or conditions inspected and their exact location:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
13. State the names and titles of the Company representatives who accompanied the
OSHA inspector during the inspection tour:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
14. State the names and titles of employee (union) representatives who accompanied
the OSHA inspector during the inspection tour:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
15. Describe the route taken by the OSHA inspector during the inspection tour:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
16. Describe in detail any relevant remarks made during the inspection by both
the OSHA inspector and any employees, identifying the speaker:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
17. Describe in detail any objections made during the inspection:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
18. Identify any photographs taken by the OSHA inspector, including location,
time of day, date, and the names of any employees in the photograph:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Did you request copies of the photographs taken by the OSHA inspector? ________
19. Identify any photographs taken by a management representative, including
photographer, location, time of day, date, and the names of any employees
in the photograph:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
20. Describe any monitoring conducted by the OSHA inspector, including the
equipment used, monitoring procedure, time of day, date, and the results
of such monitoring, if known:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
21. List the names of any employees interviewed by the OSHA inspector and state
whether a management representative was present during the interview. If a
management representative was present, state the name of the employee
interviewed and a summary of the interview:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
22. Describe any area identified as containing or possibly revealing a trade
secret:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
A. State the time and date when you made the compliance officer aware of
areas containing trade secrets:
________________________________________________________________________
B. Did you hand a copy of the letter identifying trade secrets addressed
to the Area Director of OSHA to the OSHA inspector?
________________________________________________________________________
Time and date letter given to compliance officer: __________________
Did you send the letter identifying trade secrets to the Area
Director? __________
Attach a copy of the letter identifying trade secrets mailed to the
Area Director.
C. List any materials that were labeled "confidential trade secret":
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
23. Describe in detail any remarks made during the closing conference and identify
the speaker. (Include the reason why the inspector will recommend a citation
and what abatement method he recommends):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
LETTER #1
Area Director
Occupational Safety and Health Administration
U.S. Department of Labor
Dear Area Director,
It is the policy of the (Company)
to cooperate with any government agency enforcing federal, state or local
laws or regulations. It is also important to (COMPANY) that these laws
and regulations are enforced in accordance with the safeguards of the
United States Constitution. We have been advised by our legal counsel that
inspections of a company's facilities, without the employer's consent, are
unconstitutional in the absence of a valid search warrant. Because we do
not desire to waive our Fourth Amendment rights under the United States
Constitution, we are refusing to admit you to our plant. Should you deem
it necessary to obtain an administrative search warrant for the purpose of
conducting an inspection, please notify me so that the Company may be present
when application for the warrant is made.
A copy of this letter was read to the Compliance Safety and Health Officer
under your supervision.
Very truly yours,
LETTER #2
Area Director
Occupational Safety and Health Administration
U.S. Department of Labor
Dear Area Director,
A Compliance Officer under your supervision has asked to inspect (specific
area referred to in the employee complaint, accident report, or area
previously cited) on date . The (Company) has complied with this request.
The inspection, however, is with the consent of the (company) only as to the
(specific areas identified above). Should the scope of the inspection exceed
our consent, reserves its right to challenge the validity of the inspection,
to seek the exclusion of any evidence obtained as a result of the inspection,
and to seek the dismissal of any citations issued as a result of the inspection.
A copy of this letter was hand-delivered to the Compliance Officer before he
began the inspection.
Very truly yours,
LETTER #3
Area Director
Occupational Safety and Health Administration
U.S. Department of Labor
Dear Area Director,
A Compliance Officer under your supervision presented a search warrant and
requested to inspect this Company's premises on (Date) . The Company
has complied with the request. The inspection, however, is totally without
the consent of this Company and it is permitting the Compliance Officer to
enter its premises under protest. We reserve our right to challenge the
validity of the inspection, to seek the exclusion of any evidence obtained as
a result of the inspection, and to seek the dismissal of any citations issued
as a result of the inspection.
A copy of this letter was hand-delivered to the Compliance Officer before he
began the inspection.
Very truly yours,
LETTER #4
Area Director
Occupational Safety and Health Administration
U.S. Department of Labor
Dear Area Director:
A Compliance Safety and Health Officer under your supervision has requested
to inspect (specific areas which contain or might reveal a trade secret) of
(Company) on (date). Since the described areas contain or might reveal a
trade secret, we are requesting that any information obtained by the
Compliance Safety and Health Officer in such areas, including all photographs
and samples, be labeled "confidential - trade secret," and we insist that
OSHA treat them confidentially pursuant to OSHA rules and regulations. In the
event we have overlooked a confidential product or process during the present
inspection, we reserve the right to bring these to OSHA's attention at a later
date with the expectation that OSHA will treat them with confidentiality.
A copy of this letter was hand-delivered to the Compliance Officer before he
began inspecting areas which contain or might reveal a trade secret.
Very truly yours,
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