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University of California, Berkeley

GENERAL SELF-INSPECTION FORM
for Administrative Areas

This self-inspection form should be used to document safety inspections in large office suites, areas with multiple cubicles, copy rooms, coffee rooms, and other common work areas. It should not be used for individual offices, nor for non-administrative areas such as shops, laboratories, and areas containing any hazardous materials. (See the IIPP Form Directory for additional Office, Shop, and Laboratory forms.)

The university is required to perform and document self-inspections of all campus workspaces annually as part of Cal/OSHA’s requirement for an effective Injury and Illness Prevention Program (IIPP). Each department must inspect its administrative workspaces annually using this GENERAL/ADMINISTRATIVE SELF-INSPECTION FORM or an equivalent. This form can assist you in identifying and correcting many unsafe practices and conditions. The unsafe practices and conditions identified on this form are prohibited by state laws or campus policies, or are generally considered to be unsafe workplace practices.

After completing the self-inspection form, share the results with your supervisor and Department Safety Committee. Correct identified deficiencies as soon as possible and document correction on the form by entering the "Date Completed." If you need assistance correcting conditions, or if you have any questions or concerns about safety in the workplace, contact your Department Safety Coordinator or the Office of Environment, Health & Safety (EH&S) at 642-3073. Keep the original self-inspection form on file in your department, so that it will be available should Cal/OSHA or campus oversight committees request it. EH&S will periodically check that your department has performed and documented general (administrative area) self-inspections.

This form was designed to help ensure compliance with Cal/OSHA regulations that require documented periodic inspections of all work areas as part of an effective IIPP. However, completion of this form and correction of any findings noted herein does not ensure that Cal/OSHA will not issue citations.

University of California, Berkeley

GENERAL SELF-INSPECTION FORM
for Administrative Areas


Area Location (Rm/Bldg):

 Type of Area:
Department: Date of Inspection:
Inspector's Name (print) Signature:

Supervisor's Name (print):

 Signature:


Please check the boxes indicating Yes (satisfactory), No (needs correction), or N/A (not applicable).

1. Is the Cal/OSHA poster "Safety and Health Protection on the Job" displayed in the building and accessible to all employees?

Ο  Yes (Satisfactory)    Ο No (Needs Correction)  Date Corrected:   ______________    Ο   N/A

Corrective Action: Contact EH&S (642-3073) to obtain posters.

 

2. Is documentation of safety training, workplace self-inspections, and hazard corrections maintained and accessible where indicated in your department’s IIPP?

Ο  Yes (Satisfactory)    Ο No (Needs Correction)  Date Corrected:   ______________    Ο   N/A

Corrective Action: Confirm location listed in the IIPP and ensure that records are stored there.

 

3. Have employees in the area been trained on the applicable Building Emergency Plan (BEP)?

Ο  Yes (Satisfactory)    Ο No (Needs Correction)  Date Corrected:   ______________    Ο   N/A

Corrective Action: Contact your Department Safety Coordinator to obtain the BEP, or contact your Building Coordinator if a BEP is not available.

 

4. Are evacuation diagrams posted?

Ο   Yes (Satisfactory)    Ο No (Needs Correction)  Date Corrected:   ______________    Ο   N/A

Corrective Action: Contact your Department Safety Coordinator, Building Coordinator, or EH&S (642-3073) for assistance in preparing diagrams as required by the BEP.

 

5. Are fire alarm pull boxes clearly identifiable and unobstructed?

Ο  Yes (Satisfactory)    Ο No (Needs Correction)  Date Corrected:   ______________    Ο   N/A

Corrective Action: Clear area of obstructions.

 

6. Are fire hose stations and/or portable extinguishers clearly identifiable and unobstructed?

Ο  Yes (Satisfactory)    Ο No (Needs Correction)  Date Corrected:   ______________    Ο   N/A

Corrective Action: Label fire-fighting equipment and clear area of obstructions.

 

7. Are fire extinguishers tagged with inspections at least annually?

Ο  Yes (Satisfactory)    Ο No (Needs Correction)  Date Corrected:   ______________    Ο   N/A

Corrective Action: Contact your Building Coordinator to arrange for a fire extinguisher inspection by PP-CS. Ensure that the extinguisher is properly tagged after the inspection.

 

8. Do self-closing devices and door latches on fire-rated doors (doors that open into corridors or stairwells) work properly? (Doorstops are not permitted.)

Ο  Yes (Satisfactory)    Ο No (Needs Correction)  Date Corrected:   ______________    Ο   N/A

Corrective Action: Contact your Department Safety Coordinator to arrange for door repairs.

 

9. Are there at least 18 inches (47 cm) of vertical clearance maintained between all stored items and any ceiling equipped with fire sprinklers?

Ο  Yes (Satisfactory)    Ο No (Needs Correction)  Date Corrected:   ______________    Ο   N/A

Corrective Action: Remove stored items that do not meet the above criteria.

 

10. Are electrical panels accessible and circuit breakers clearly identified?

Ο  Yes (Satisfactory)    Ο No (Needs Correction)  Date Corrected:   ______________    Ο   N/A

Corrective Action: Label circuit breakers as to their function, and clear area in front of electrical panels by 36 inches.

 

11. Are aisles, exits, and adjoining hallways maintained free of obstructions so that the area can be easily evacuated or accessed in case of an emergency?

Ο  Yes (Satisfactory)    Ο No (Needs Correction)  Date Corrected:   ______________    Ο   N/A

Corrective Action: Remove obstructions from aisles, exits, and adjoining hallways. Contact your Department Safety Coordinator if help is needed cleaning adjoining hallways.

 

12. Has all electrical equipment that is required to be grounded (e.g., copiers and computers) been grounded? (Ensure that the grounding pin has not been removed and that 3-pin to 2-pin adapters are not used.)

Ο  Yes (Satisfactory)    Ο No (Needs Correction)  Date Corrected:   ______________    Ο   N/A

Corrective Action: Contact your supervisor or Department Safety Coordinator to arrange for installation of appropriate outlets and plugs.

 

13. Are extension cords in good condition (e.g., no breaks or exposed wiring), used only as temporary wiring (less than 30 days), and not connected in series?

Ο   Yes (Satisfactory)    Ο No (Needs Correction)  Date Corrected:   ______________    Ο   N/A

Corrective Action: Do not connect extension cords in series. Dispose of or repair all electrical cords that are not in good condition, and replace those in use more than 30 days with permanent wiring.

 

14. Has all broken, unguarded, or otherwise dangerous equipment and furniture been repaired or removed? (Example: A papercutter without a guard to keep fingers away from the blade.)

Ο  Yes (Satisfactory)    Ο No (Needs Correction)  Date Corrected:   ______________    Ο   N/A

Corrective Action: Contact your supervisor or Department Safety Coordinator to arrange for removal or repair of equipment or furniture.

 

15. Are floor surfaces kept dry and/or made slip-resistant?

Ο  Yes (Satisfactory)   Ο No (Needs Correction)  Date Corrected:   ______________    Ο   N/A

Corrective Action: Work with your supervisor, Department Safety Coordinator, or Safety Committee to address this issue.

 

16. Is furniture and equipment over four feet tall braced to prevent tipping in an earthquake?

Ο  Yes (Satisfactory)    Ο No (Needs Correction)  Date Corrected:   ______________    Ο   N/A

Corrective Action: Contact your supervisor or Department Safety Coordinator for assistance in installing seismic restraints, or remove items in question.

 

17. Are all work areas adequately illuminated?

Ο   Yes (Satisfactory)    Ο No (Needs Correction)  Date Corrected:   ______________    Ο   N/A

Corrective Action: Contact your supervisor or Department Safety Coordinator for assistance in obtaining additional lighting.

 

18. Have computer workstations been ergonomically evaluated for all employees who spend four or more hours at their computer each day?

Ο   Yes (Satisfactory)    Ο No (Needs Correction)  Date Corrected:   ______________    Ο   N/A

Corrective Action: Contact your supervisor or Department Safety Coordinator to have a trained workstation evaluator assess the workstation. If your department does not have an evaluator, contact University Health Services, Ergonomics@Work Program (642-8410).

 
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