Ergo/Safety Surveillance Tool

Facility: ___________________ Date Completed: __/___/____	Conducted by: ________________________

After reading each location and the hazard description, select the number in the corresponding cell that most accurately represents how the hazard description applies to the area of the facility. Specific notes can and should be added for each location, including room numbers and description of issues for each observation.

Food Preparation

Location	Hazard Description	Does not apply at all	0 %	25 %	50 %	75 %	100 %
Food Preparation	Food preparation areas are free of slip, trip, and fall (STF) hazards, struck by/against, caught-in-between and collision hazards. This includes but is not limited to:	0	1	2	3	4	5
The floor is clear of debris (boxes and other clutter).
Access and egress are clear.
Equipment is stored out of the way when not in use.
There are no wet/oily spills on the floor.
Machines are suitably anchored to prevent creeping or tipping (i.e., wheel locks or wall bolts).
Machine guarding is in place where appropriate (e.g., guards on mixers to prevent bodies or appendages from encountering the mixing blades when in operation, guards on slicing machines).
Hazard warning signs are available (i.e., “wet floor”, 35” safety cones).
Employees are wearing non-slip shoes.
The floor around fat disposal containers is clean.
There are no wrinkled mats presenting a STF hazard.
Floor cleaning materials are easily accessible. Ask a random employee to show them to you.
There is adequate lighting.
Ask a random employee to show you what to do if they encountered an immediate hazard When performing the assessment were there any additional housekeeping hazards or concerns noted?

Location	Hazard Description	Does not apply at all	0 %	25 %	50 %	75 %	100 %
Food Preparation	Food preparation areas should be free of musculoskeletal disorder (physical) hazards involving posture, lifting, pushing, pulling & standing. This includes but is not limited to:	0	1	2	3	4	5
Commonly used tools are within easy reaching access and between knee and shoulder height.
Anything heavier than a gallon of milk should be within shoulder to knee height.
Electrical outlets are easy to access and between knee and shoulder height.
A good footstool or other height assistance with good tread and locking heels is available to reach overhead work and keep movements between the shoulders and knees.
There are carts or other mechanical assistance for moving heavy/bulky/hot items.
Equipment is regularly maintained to promote easier pushing and pulling. Wheels/castors/etc. are in good condition.
The lightest items are stored below and above the knee to shoulder area.
Nothing is stored above 72”.
Chairs/stools (if available) are adjustable with arm rest supports.
Workstations/benches are adjustable wherever possible (height of workstation, space to move tools around and customize layout, etc.)
Equipment is easily accessible without excessive bending, twisting, pushing, or pulling.
There are anti-fatigue or other rubber mats at workstations where workers stand for long periods of time.
Ask a random employee to show you what to do if they encountered an immediate hazard (i.e., where to find a cart or how to report/deal with a broken one) Observe them dumping trash into the main dumpster area, not just in the food prep room. Note configuration of the trash bin (i.e., dumpster below the grade of the floor; parking lot where they have to heave the bag into it) Measure the working surface heights, record in the notes. Are working surface heights adjustable? When performing the assessment were there any additional awkward posture hazards or concerns noted?

Dish Room Area(s)

Location	Hazard Description	Does not apply at all	0 %	25 %	50 %	75 %	100 %
Dish Room Area(s)	Dish room areas are free of slip, trip, and fall (STF) hazards, struck by/against, caught-in-between and collision hazards. This includes but is not limited to:	0	1	2	3	4	5
The floor is clear of debris (boxes and other clutter).
Access and egress are clear.
There are no wrinkled mats presenting a STF hazard.
Equipment is stored out of the way
There are no wet/oily spills on the floor (likely is wet, mats should take care of most of the hazard here).
Employees are wearing non-slip shoes.
Machines are suitably anchored to prevent creeping or tipping when appropriate.
Machine guarding is in place where appropriate.
Hazard warning signs are available (i.e., “wet floor”, 35” safety cones).
Glass boxes are available for sharp broken dishes.
There is adequate lighting.
Floor cleaning materials (mops and pails) are easily accessible. Ask a random employee to show them to you.
Ask a random employee to show you what to do if they encountered an immediate hazard When performing the assessment were there any additional housekeeping hazards or concerns noted?
Dish Room Area(s)	Dish room areas should be free of musculoskeletal disorder (physical) hazards involving posture, lifting, pushing, pulling and standing. This includes but is not limited to:
There are carts or other mechanical assistance for moving heavy/bulky/hot items.
There are anti-fatigue or other rubber mats at workstations where workers stand for long periods of time.
Are working surface heights adjustable? Measure the working surface heights, record in the notes. When performing the assessment were there any additional awkward posture hazards or concerns noted?

Food Service Area(s)

Location	Hazard Description	Does not apply at all	0 %	25 %	50 %	75 %	100 %
Food Service Area(s)	Food service areas are free of slip, trip, and fall (STF) hazards, struck by/against, caught-in-between and collision hazards. This includes but is not limited to:	0	1	2	3	4	5
The floor is clear of debris (boxes and other clutter).
Access and egress are clear.
There are no wrinkled mats presenting a STF hazard.
Equipment is stored out of the way.
There are no wet/oily spills on the floor.
Machines are suitably anchored to prevent creeping or tipping where appropriate.
Machine guarding is in place where appropriate.
Hazard warning signs are available (i.e., “wet floor”).
Employees are wearing non-slip shoes.
Floor cleaning materials are easily accessible. Ask a random employee to show them to you.
Ask a random employee to show you what to do if they encountered an immediate hazard When performing the assessment were there any additional housekeeping hazards or concerns noted?

Location	Hazard Description	Does not apply at all	0 %	25 %	50 %	75 %	100 %
Food Service Area(s)	Food service areas should be free of musculoskeletal disorder (physical) hazards involving posture, lifting, pushing, pulling and standing. This includes but is not limited to:	0	1	2	3	4	5
Commonly used tools are within easy reaching access and between knee and shoulder height.
Anything heavier than a gallon of milk should be within shoulder to knee height.
Electrical outlets are easy to access and between knee and shoulder height.
There are carts or other mechanical assistance for moving heavy/bulky/hot items.
Equipment is regularly maintained to promote easier pushing and pulling. Wheels/castors/etc. are in good condition.
Nothing is stored above 72”.
Chairs/stools (if available) are adjustable with arm rest supports.
Workstations are adjustable wherever possible (height of workstation, space to move tools around and customize layout, etc).
Equipment is easily accessible without excessive bending, twisting, pushing, or pulling.
There are anti-fatigue or other rubber mats at workstations where workers stand for long periods of time.
Ask a random employee to show you what to do if they encountered an immediate hazard (i.e., where to find a cart or how to report/deal with a broken one) Measure the working surface heights, record in the notes. Are working surface heights adjustable? When performing the assessment were there any additional awkward posture hazards or concerns noted?

Walkways & Stairwells

Location	Hazard Description	Does not apply at all	0 %	25 %	50 %	75 %	100 %
Walkways/ Stairwells	Walkways are free of slip, trip, and fall (STF) hazards, struck by/against, caught-in-between and collision hazards. This includes but is not limited to:	0	1	2	3	4	5
The floor is clear of debris (boxes and other clutter).
Access and egress should are clear.
There are no wrinkled mats presenting a STF hazard.
No equipment is stored in the walkways.
There are no wet/oily spills on the floors/stairs.
Employees are wearing non-slip shoes.
Hazard warning signs are available (i.e., “wet floor”).
Floor cleaning materials are easily accessible. Ask a random employee to show them to you.
Handrails are provided on all stairs.
Adequate lighting in walkways and stairwells.
Ask a random employee to show you what to do if they encountered an immediate hazard When performing the assessment were there any additional housekeeping hazards or concerns noted?
Location	Hazard Description	Does not apply at all	0 %	25 %	50 %	75 %	100 %
Walkways/Stairwells	Walkways should be free of musculoskeletal disorder (physical) hazards involving posture, lifting, pushing and pulling.	0	1	2	3	4	5
Were there any additional musculoskeletal disorder hazards or concerns noted?

Storage Area(s)

Location	Hazard Description	Does not apply at all	0 %	25 %	50 %	75 %	100 %
Storage Area(s)	Storage areas are free of slip, trip, and fall (STF) hazards, struck by/against, caught-in-between and collision hazards. This includes but is not limited to:	0	1	2	3	4	5
The floor is clear of debris (boxes and other clutter).
Access and egress are clear.
There are no wrinkled mats presenting a STF hazard.
Equipment is stored out of the way.
There are no wet/oily spills on the floor.
Employees are wearing non-slip shoes.
Hazard warning signs are available (i.e., “wet floor”).
Floor cleaning materials are easily accessible. Ask a random employee to show them to you.
Adequate lighting in the area.
Ask a random employee to show you what to do if they encountered an immediate hazard When performing the assessment were there any additional housekeeping hazards or concerns noted?

Location	Hazard Description	Does not apply at all	0 %	25 %	50 %	75 %	100 %
Storage Areas	Storage areas should be free of musculoskeletal disorder (physical) hazards involving posture, lifting, pushing and pulling. This includes but is not limited to:	0	1	2	3	4	5
Anything heavier than a gallon of milk should be within shoulder to knee height.
A good footstool or other height assistance with good tread and locking heels is available to reach overhead work and keep movements between the shoulders and knees.
Most frequently accessed items are within shoulder and knee height.
There are carts or other mechanical assistance for moving heavy/bulky/hot items.
Equipment is regularly maintained to promote easier pushing and pulling. Wheels/castors/etc. are in good condition.
The lightest (and infrequently used) items are stored below and above the knee to shoulder area
Nothing is stored above 72”.
Equipment is easily accessible without excessive bending, twisting, pushing, or pulling. Heavy equipment is located within knee and shoulder height.
Goods have been removed from cartons prior to being placed on shelves.
There is a place to stage cartons while unpacking them (i.e., able to be raised off the floor to prevent repetitive bending).
Empty cartons are disposed of in a timely manner.
Ask a random employee to show you what to do if they encountered an immediate hazard (i.e., where to find a cart or how to report/deal with a broken one) Measure the working surface heights, record in the notes. Are working surface heights adjustable? When performing the assessment were there any additional awkward posture hazards or concerns noted?

Cold Storage Area(s)

Location	Hazard Description	Does not apply at all	0 %	25 %	50 %	75 %	100 %
Cold Storage Area(s)	Cold storage areas are free of slip, trip, and fall (STF) hazards, struck by/against, caught-in-between and collision hazards. This includes but is not limited to:	0	1	2	3	4	5
The floor is clear of debris (boxes and other clutter).
Access and egress should be clear.
There are no wrinkled mats presenting a STF hazard.
Equipment is stored out of the way.
There are no wet/oily spills.
Employees are wearing non-slip shoes.
Hazard warning signs are available (i.e., “wet floor”).
The floor is free of ice.
Floor cleaning materials are easily accessible. Ask a random employee to show them to you.
Adequate lighting in the cold storage area.
Ask a random employee to show you what to do if they encountered an immediate hazard When performing the assessment were there any additional housekeeping hazards or concerns noted?

Location	Hazard Description	Does not apply at all	0 %	25 %	50 %	75 %	100 %
Cold Storage Areas	Cold storage areas should be free of musculoskeletal disorder (physical) hazards involving posture, lifting, pushing and pulling. This includes but is not limited to:	0	1	2	3	4	5
Anything heavier than a gallon of milk should be within shoulder to knee height.
A good footstool or other height assistance with good tread and locking heels is available to reach overhead work and keep movements between the shoulders and knees.
There are carts or other mechanical assistance for moving heavy/bulky/hot items.
Equipment is regularly maintained to promote easier pushing and pulling. Wheels/castors/etc. are in good condition.
The lightest items are stored below and above the knee to shoulder area.
Nothing is stored above 72”.
Goods have been removed from cartons prior to being placed on shelves.
There is a place to stage cartons while unpacking them (i.e., able to be raised off the floor to prevent repetitive bending).
Empty cartons are disposed of in a timely manner.
Ask a random employee to show you what to do if they encountered an immediate hazard (i.e., what to do if there is ice on the floor) Measure the working surface heights, record in the notes. Are working surface heights adjustable? When performing the assessment were there any additional awkward posture hazards or concerns noted?

Cashier Area

Location	Hazard Description	Does not apply at all	0 %	25 %	50 %	75 %	100 %
Cashier Areas	Cashier areas are free of slip, trip, and fall (STF) hazards, struck by/against, caught-in-between and collision hazards. This includes but is not limited to:	0	1	2	3	4	5
The floor is clear of debris (boxes and other clutter).
Access and egress should are clear.
There are no wrinkled mats presenting a STF hazard.
There are no wet/oily spills.
Employees are wearing non-slip shoes.
Hazard warning signs are available (i.e., “wet floor”).
Floor cleaning materials are easily accessible. Ask a random employee to show them to you.
Ask a random employee to show you what to do if they encountered an immediate hazard When performing the assessment were there any additional housekeeping hazards or concerns noted?

Location	Hazard Description	Does not apply at all	0 %	25 %	50 %	75 %	100 %
Cashier Areas	Cashier areas should be free of musculoskeletal disorder (physical) hazards involving posture, lifting, pushing , pulling and standing. This includes but is not limited to:	0	1	2	3	4	5
Commonly used tools are within easy reaching access and between knee and shoulder height.
There are anti-fatigue or other rubber mats at workstations where workers stand for long periods of time.
Anti-fatigue floor mats are in good condition.
Chairs or stools are available to employees.
Chairs are adjustable with arm rest supports.
Equipment is regularly maintained to promote easier pushing and pulling. Wheels/castors/etc are in good condition.
Leg wells are clear.
Monitor is directly in front of the user.
Workstations are adjustable wherever possible (registers, height of workstation, space to move tools around and customize layout, etc).
Ask a random employee to show you what to do if they encountered an immediate hazard (i.e., how to report/deal with a broken chair) Measure the working surface heights, record in the notes. Are working surface heights adjustable? When performing the assessment were there any additional awkward posture hazards or concerns noted?

Restrooms

Location	Hazard Description	Does not apply at all	0 %	25 %	50 %	75 %	100 %
Restrooms	Restrooms are free of slip, trip, and fall (STF) hazards, struck by/against, caught-in-between and collision hazards.. This includes but is not limited to:	0	1	2	3	4	5
The floor is clear of debris (boxes and other clutter).
Access and egress should be clear.
There are no wrinkled mats presenting a STF hazard.
There are no wet spills on the floor.
Hazard warning signs are available (i.e., “wet floor”).
When performing the assessment were there any additional housekeeping hazards or concerns noted? Any other types of hazards or concerns noted?

Other

Location	Hazard Description	Does not apply at all	0 %	25 %	50 %	75 %	100 %
Other	When performing the assessment, were there any additional STF, housekeeping, or musculoskeletal disorder hazards/concerns noticed at the facility?