MODEL CHECKLIST
YOUNG WORKER SAFETY ORIENTATION
This checklist is a guideline for conducting a safety orientation for young workers. Once completed and signed by both the supervisor and the worker, it serves as documentation that a proper orientation has taken place.
Worker’s Name: _____________________________
Supervisor’s Name: __________________________
Date Worker Started: __________________________
Date of Orientation: ___________________________
Name of Person Giving the Orientation: ________________________________________________________
Place a check in each box to indicate that the topic has been covered.
Explanation of the company safety program, including:
Orientation
On-the-job training
Safety meetings
Incident investigation and reporting
Function of the safety committee (if there is one)
Personal Protective Equipment
Hard hats
Safety glasses
High visibility vests
Rubber gloves
Respiratory protective equipment
Other protective equipment specific to job
Lines of Communication and Responsibility for Reporting Incidents:
When to report an injury
How to report an injury
To whom an injury should be reported
Filing an incident report form
Reporting “near misses”
Review Hazards Specific to Job Duties
Physical hazards (ladders, electricity, repetitive work, hot oil, etc.)
Chemical hazards (cleaning chemicals, toxic substances, dust, paint, asbestos, etc.)
Biological hazards (bacteria, viruses, fungi, mold, insects, etc.)
Ergonomic hazards (work station design, lifting, repetitive movements, etc.)
First Aid Supplies, Equipment and Training
Obtaining first aid treatment
Location of first aid stations
Location and names of staff with first aid training
Emergency Plan
Exit locations and evacuation routes
Use of firefighting equipment (extinguisher, hose)
Specific procedures (medical, chemical, fire, etc.)
Vehicle Safety Check Procedure
Safety and speed regulations
Operating license appropriate for vehicle
Personal Work Habits
Inattention
Smoking policy
Good housekeeping practices
Filing an incident report form
Proper lifting techniques
Other Health and Safety Items
Add any other health and safety items the worker needs to know about your workplace, such as security procedures for working alone. You may need to provide education and training for these at another time.
________________________________________________________
________________________________________________________
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The signatures below are evidence that the topics contained in this checklist have been discussed to the satisfaction of the worker and supervisor. Signing indicates that both parties accept responsibility for maintaining a safe and healthy workplace.
Supervisor’s Signature: _____________________________________
Worker’s Signature: ________________________________________
Date: __________________
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