ConsumersEnergy–Health&SafetyScreening Assessment AlimitedHealth&Safetyscreeningassessmentbasedonvisual observations,interviews,anddocumentsprovided.ThisisNOTa formalMIOSHAcomplianceaudit.Findingsareintendedtoidentify potentialgapsandsupportcorrectiveactionplanning. 1 / 21 ConsumersEnergy–H&SScreeningAssessment DISCLAIMER:Thisreportisbasedonvisualobservations,interviews,and documentsprovidedatthetimeoftheassessment.ItisalimitedHealth& SafetyscreeningassessmentandisNOTaformalMIOSHAcompliance audit.Findingsareintendedtoidentifypotentialgapsandobservationsto supportcorrectiveactionplanning.Regulatorycompliancedeterminations requireaformalauditbyaqualifiedcomplianceprofessional. Instruction Site/Facility Textanswer FacilityAddress/Location Textanswer FacilityName Textanswer LeadInspectorName(CSP) Textanswer PartnerConsultantName Textanswer 2 / 21 ConsumersEnergyDesignatedContact Textanswer InspectionDate Date/time EnterDateandTime: / / : AM/PM FacilityType Selectone []Office []Warehouse []Manufacturing []Fleet []Laboratory []Healthcare []UtilityOperations []Other 3/ 21 SiteWalk-Through RequiredSitePhotos Capturephotographsofelectricalrooms,mechanicalrooms,utilityvault accesspoints,generatorrooms,boilerrooms,mainelectricalequipment, andanypotentialconfinedspaceaccesspointswheresafelyaccessible.Do notenterconfinedspaces,vaults,pits,tanks,crawlspaces,orother enclosedspaces.Photographfromoutsidethespaceonly. Instruction *BuildingExterior–Photo Media *SafetyBulletinBoard–Photo Media *FireExtinguisher–Photo Media *FirstAidStation–Photo Media *EvacuationMap–Photo Media *ElectricalArea–Photo Media *ChemicalStorageArea–Photo Media ElectricalRoom(s)–Photo(wheresafely accessible) Media MechanicalRoom(s)–Photo(wheresafely accessible) Media UtilityVaultAccessPoints–Photo(where safelyaccessible) Media GeneratorRoom(s)–Photo(wheresafely accessible) Media BoilerRoom(s)–Photo(wheresafely accessible) Media MainElectricalServiceEquipment–Photo (wheresafelyaccessible) Media 4 / 21 PotentialConfinedSpaceAccessPoints (manholes,vaults,pits,tanks,crawlspaces, sumps,etc.)–Photo(wheresafely accessible) Media *IdentifiedFindings–Photo(s) Media Conductarepresentativewalk-throughofallaccessiblefacilityareas. Documentobservedconditionsandunsafeacts.Note:Observationsare limitedtoareasaccessibleduringtheassessment. Instruction Areas/ZonesInspectedDuringWalk-Through Textanswer Escort/FacilityRepresentativeDuringWalk-Through Textanswer Werealltargetareasaccessibleduringthewalk-through? Selectone []Yes []No []N/A Ifareaswereinaccessible,describewhichareasandreason Textanswer OverallFacilityHousekeeping&Organization Selectone []Good []Fair 5/21 []Poor []N/A FacilityOverviewPhotos Media FallProtection&Walking-WorkingSurfaces Adequatefallprotectionobservedwherefallhazardsexist? Selectone []Yes []No Flooropeningsandholesguarded? Selectone []Yes []No Triphazardsobserved? Selectone []Yes []No Laddersingoodconditionandusedproperly? Selectone []Yes []No SupportingPhotos Media MachineGuarding&EquipmentSafety Machineryhasadequatepoint-of-operationguarding? Selectone []Yes []No Movingparts(belts,pulleys,gears)properlyguarded? Selectone 6/ 21 []Yes []No Machineguardsingoodconditionandnotbypassed? Selectone []Yes []No Emergencystopcontrolsaccessibleandfunctional? Selectone []Yes []No SupportingPhotos Media ElectricalSafety Noexposedenergizedwiringorelectricalcomponentsobserved? Selectone []Yes []No Electricalpanelsaccessibleandunobstructed? Selectone []Yes []No Electricalcordsingoodcondition? Selectone []Yes []No Electricalsafetyconcernsobservedinwetordampareas? Selectone []Yes []No 7/ 21 Junctionboxesandconduitscovered? Selectone []Yes []No SupportingPhotos Media HazardousMaterials&HazCom Chemicalcontainerslabeled? Selectone []Yes []No SDSaccessibletoemployees? Selectone []Yes []No Chemicalsproperlystored? Selectone []Yes []No Secondarycontainmentpresentwhereneeded? Selectone []Yes []No ChemicalsofConcernIdentified Textanswer SupportingPhotos Media 8/ 21 EmergencyPreparedness&FireSafety Emergencyexitsclearandaccessible? Selectone []Yes []No Fireextinguisherspresent,tagged,andaccessible? Selectone []Yes []No Evacuationmapsposted? Selectone []Yes []No Firstaidkitspresentandstocked? Selectone []Yes []No Emergencyeyewash/showerstationspresentandfunctional? Selectone []Yes []No Emergencyalarmsystemsfunctional? Selectone []Yes []No SupportingPhotos Media PoweredIndustrialTrucks(Forklifts) Forkliftpre-operationinspectionchecklistscompleted? Selectone 9/ 21 []Yes []No Forkliftsingoodcondition(novisibledamageordefects)? Selectone []Yes []No Forkliftandpedestriantrafficadequatelyseparated? Selectone []Yes []No Forkliftoperatorswearingseatbelts? Selectone []Yes []No SupportingPhotos Media PersonalProtectiveEquipment(PPE) PPErequirementspostedinworkareas? Selectone []Yes []No EmployeesobservedwearingappropriatePPE? Selectone []Yes []No RequiredPPEavailableandingoodcondition? Selectone []Yes []No 10/ 21 SupportingPhotos Media Lockout/Tagout(LOTO) LOTOproceduresorcontrolsobservedwhereapplicable? Selectone []Yes []No LOTOhardware(locks,tags,hasps)availableatpointofuse? Selectone []Yes []No NoevidenceofLOTObeingbypassed? Selectone []Yes []No SupportingPhotos Media PotentialConfinedSpaces Documentonlyspacesthatappeartobepits,tanks,vaults,crawlspaces, manholes,sumps,tunnels,vessels,orotherenclosedspaces.Donot determinewhetheraspacemeetsMIOSHAconfinedspaceor permit-requiredconfinedspacecriteria.Detailedevaluationwillbe performedbyPartnerEHSprofessionalsduringtechnicalreview. Instruction Potentialconfinedspacesobservedon-site? Selectone []Yes []No []Unknown Describeobservedspaces. Textanswer 11/ 21 SupportingPhotos Media 12/ 21 PersonnelInterviews Askthefacilityrepresentativethefollowingbriefquestions.Record responsesbelow.DetailedprogramreviewswillbecompletedbyPartner EHSprofessionalsusingtheLEHSCRquestionnaire. Instruction NameofInterviewee#1 Textanswer Title/RoleofInterviewee#1 Textanswer Isthereadesignatedsafetycontacton-site? Selectone []Yes []No []N/A SafetyContactNameandTitle Textanswer Areemployeesawareofhazardreportingprocedures? Selectone []Yes []No []N/A 13 / 21 Areemployeesawareofemergencyprocedures? Selectone []Yes []No []N/A HasthefacilityreceivedanyMIOSHAinspections,citations,or enforcementactionsinthelast5years? Selectone []Yes []No []Unknown Additionalcomments Textanswer 14/ 21 Findings&CorrectiveActions FINDINGSEVERITYDEFINITIONS: •High–Immediateinjuryorlifesafetyconcernrequiringurgentcorrective action. •Medium–Correctiveactionrecommended;notanimmediatelifesafety concern. •Low–Housekeepingorbestpracticeimprovementopportunity. Instruction Documentallobservedhealth&safetyfindingsfromthesite walk-through.Foreachfinding,recordadescription,severity, recommendedcorrectiveaction,andphoto.Detailedcompliance evaluationwillbecompletedbyPartnerEHSprofessionals. Instruction TotalNumberofFindingsIdentified Number NumberofHighPriority/Immediate CorrectiveActionFindings Number NumberofMediumPriorityFindings Number NumberofLowPriority/Observation-Level Findings Number WereallrequestedLEHSCRdocumentsavailableforreview? Selectone []Yes []Partially []No []Unknown Finding#1–Description Textanswer 15 / 21 Finding#1–Severity Selectone []High–Immediateinjury/lifesafetyconcern []Medium–Correctiveactionrecommended []Low–Housekeeping/bestpracticeimprovement Finding#1–RecommendedCorrectiveAction Textanswer Finding#1–Photo Media Finding#2–Description Textanswer Finding#2–Severity Selectone []High–Immediateinjury/lifesafetyconcern []Medium–Correctiveactionrecommended []Low–Housekeeping/bestpracticeimprovement Finding#2–RecommendedCorrectiveAction Textanswer 16/ 21 Finding#2–Photo Media Finding#3–Description Textanswer Finding#3–Severity Selectone []High–Immediateinjury/lifesafetyconcern []Medium–Correctiveactionrecommended []Low–Housekeeping/bestpracticeimprovement Finding#3–RecommendedCorrectiveAction Textanswer Finding#3–Photo Media AdditionalFindings–Description,RecommendedCorrectiveAction, Severity,andBasis Textanswer 17/ 21 Wereanyimmediatelydangeroustolifeorhealth(IDLH)conditions observed? Selectone []Yes []No []N/A IfanswerisYes RequireAction IfanswerisYes RequireEvidence IDLHConditionDescription(ifapplicable) Textanswer Isafollow-upvisitorre-inspectionrecommended? Selectone []Yes []No []N/A 18/21 EHSTechnicalReviewerUseOnly ThissectionisforusebytheEHSTechnicalRevieweronly.Completeall applicablefieldsafterreceivingthefieldassessmentandLEHSCR questionnairedocumentsfromtheclient. Instruction AdditionalDocumentReviewNotes Textanswer Follow-UpRecommendations Textanswer ReviewerNarrative/TechnicalSummary Textanswer 19 / 21 RecommendedNextSteps/Re-AssessmentRequired? Textanswer EHSTechnicalReviewerSignature Signature Date: / / DateofTechnicalReview Date/time EnterDateandTime: / / : AM/PM 20/ 21