Basic Electrical Safety Initial Questionnaire This is the initial questionnaire for Basic Electrical Safety This field is hidden when viewing the formCourse NameCompany Information1) Company Name(Required)2) Address(Required) Street Address City State / Province / Region ZIP / Postal Code 3) Company Phone(Required)4) Type of Business(Required)5) What is the maximum number of employees?(Required)This is the total number of employees (part-time or seasonal) you would have during the year.6) Safety Coordinator(Required) First Last 7) Safety Coordinator Email(Required) 8) Safety Coordinator Phone(Required)9) Building Constructed Date(Required)10) Do you have the OSHA poster?(Required) Yes No 11) Does anyone speak secondary language?(Required) Yes No LanguageExtension Cords12) Are there any extension cords used?(Required) Yes No Are there any extension cords which are not approved? Yes No LocationCorrective ActionExtension cords must be approved by a National Recognized Organization and have an approval label.Are there any extension cords longer than necessary? YES. NO LocationCorrective ActionExtension cords should not be longer than necessary. Excessive extension cords could result in voltage drops, overheating, and potential fire hazards.Are there any extension cords used with high wattage appliances? YES NO LocationCorrective ActionUsing an extension cord with a high wattage appliance could result in overheating, and potential fire hazards.Are there any extension cords which have been used longer than 90 days. YES NO LocationCorrective ActionOSHA indicates extension cords can only be used in a location for 90 days. After 90 days outlets should be installed.Are there any extension cords connected together? YES NO LocationCorrective ActionOSHA and NEC does not allow extension cords to be connected together. If necessary a longer cord should be used..Are any extension cords in wet environments not approved for these locations ? YES. NO N/A LocationCorrective ActionExtension cords should only be used in a wet environment when approved and connected to a GFCI circuit.Are there any extension cords passing through walls, windows, doors, mats, rugs, above ceilings ? YES NO LocationCorrective ActionExtension cords should not pass through walls, windows, doors, under mats, rugs, or above ceilings. The cords could either be damaged or any damage in the cord concealed.Power Strips13) Are there any power strips used?(Required) Yes No Are there any power strips used on a circuit with a higher amperage rating than the breaker ? YES NO LocationCorrective ActionExample would be a power strip with a ratting of 20 amps connected to an outlet where the breaker is only 15 amps.Are there any power strips used with amperage appliances ? YES NO This is the same as with extension cords.LocationCorrective ActionThe power strip should be eliminated. The appliance moved to a location where it can be plugged into an outlet or an outlet installed for the appliance.Are there any power strips connected together ? YES. NO .LocaionCorrective ActionDaisy chaining is not allowed per OSHA and NEC. By daisy chaining power strips you can overload the circuit causing excess heat and a potential fire. Electric Panel Boxes14) Is there anything stored within 3 feet of the panel box?(Required) YES NO LocationCorrective ActionA possible corrective action would be to mark a 3 foot square in front of the panel box and indicate15) Do employees know the location of the circuit breakers which control their area ?(Required) YES NO Corrective ActionAs part of the training to employees take them to the electric panel for the area and point out the specific breakers and what they control.16) Are the circuit breakers labeled ?(Required) YES NO. Corrective ActionHave an electrician identify and label all breakers for the area. 17) Are all blank spaces in the panel filled in with blanks ?(Required) YES NO. Corrective ActionHave an electrician install blanks in unused spaces in the panel.18) Can circuit breaker panel doors able to open minimum of 90 degrees ?(Required) YES NO. CHekc door to see it will open at lest 90 degrees.Corrective Action19) Are circuit panel doors normally closed ?(Required) YES NO. Corrective ActionBe sure panel doors are always closed. If necessary, put a small label on panel door indicating “Door closed at all times”20) Are employees aware of how to touch panel box doors ?(Required) YES NO. Corrective ActionDuring training show employees how to touch a panel door and explain if a wire becomes loose in panel it could cause a shock when touching door. Electric Receptacles21) Are the proper receptacles installed in wet locations?(Required) YES NO. Corrective ActionAny receptacle in a wet location must be protected by a GFCI breaker or a breaker in panel.22) Do any receptacles have missing or have broken covers?(Required) YES NO Any broken or missing cover plates on a receptacle should be installed or replaced. A broken or missing plate could expose the wires within. LocartionCorrective ActionGround Fault Circuit Interrupter23) Are receptacles within 6 feet or wet areas protected by a GFCI unit?(Required) YES NO N/A Think of outlets in restrooms. Be sure they are GFCI or the breaker these outlets are connected to is a GFCI breaker.Corrective Action24) Has the GFCI receptacles been tested within the last month ?(Required) YES NO N/A (If no GFCI receptacle) Location Add RemoveResult (Pass or Fail) Add RemoveCorrected (Yes or No) Add RemoveIs correction neededCorrective ActionAny outlet within 6 feet of water source needs GFCI protection.25) Has any GFCI units within a panel box tested within the last month?(Required) YES NO N/A (If not GFCI breaker) Location Add RemoveResult (Pass or Fail) Add RemoveCorrected (Yes or No) Add RemoveIs correction neededCorrective ActionAny outlet within 6 feet of water source needs a GFCI unit receptacle or connected to brreaker.Appliances26) Are there any exposed wires on electric appliances ?(Required) YES NO Corrective Action27) Do all appliances have a means of disconnecting ?(Required) YES NO Corrective Action28) Do all appliances have the required name plate ?(Required) YES NO. Corrective ActionTripping Hazards29) Are there any extension cords across floor area where someone could trip ?(Required) YES NO Corrective ActionDo you have any additional information about the Basic Electric Safety Program.This field is hidden when viewing the formQuestionnaireCommentsThis field is for validation purposes and should be left unchanged.
