Basic Electrical Safety Monthly Questionnaire This is the monthly questionnaire for Basic Electrical Safety Company Information1) Company Name(Required)2) Safety Coordinator(Required) First Last 3) SafetyCoordinator Email(Required) 4) Safety Coordinator Phone(Required)5) Name of Individual Conduction Inspection(Required)6) Date of Inspection(Required) MM slash DD slash YYYY 7) Where there any changes made since last inspection?(Required)Extension Cords8) Do you have any extension cords ?(Required) YES NO If new extension cords have been purchased, do they all have approval label? YES NO LocationCorrective ActionExtension cords have a small tag attached. Be sure these labels remain on cords.Are there any extension cords used with high amperage appliances? YES NO Type of EquipmentCorrective ActionExtension cords used on equipment should be high amperage cords.Are there any extension cords which have been used longer than 90 days. YES NO LocationCorrective ActionThe standards indicate extension cords should be used no longer than 90 days. After 90 days outlets should be installed.Are there any extension cords connected together? YES NO LocationCorrective ActionExtension cords should not be tied together. If additional length is necessary a longer extension cord should be used.Are any extension cords in wet environments not approved for these locations ? YES NO LocationCorrective ActionExtension cords in wet locations should be protected by a GFCI.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 cord could be concealed.Power Strips9) Do you have any power strips ?(Required) YES NO Are there any power strips used on a circuit with a higher amperage rating than the breaker ? YES NO LocationCorrective ActionThe total amperage of items plugged in should not exceed the total rating of the strip. Corrective action would be to either fewer plug-ins or large amperage power strip.Are there any power strips used with amperage appliances ? YES NO LocationCorrective ActionThe power strip should be eliminated. The appliance moved to location where it can be plugged in to an outlet or an outlet installed for the appliance.Are there any power strips connected together ? YES NO LocationCorrective ActionPower strips should be connected directly to outlets. Power strips can be obtained with various length cords. Daisy chaining is not allowed pe OSHA and National Electric CodeElectric Panel Boxes10) 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 area in front of the panel box and indicate “No Items in Space”11) Do all 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.12) Are the circuit breakers labeled ?(Required) YES NO Corrective ActionHave an electrician identify and label all breakers for the area.13) Are all blank spaces in the panel filled in with blanks ?(Required) YES NO Corrective ActionHave an electrician install blanks in unused spaces in panel. 15) 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 indicated “Door closed at all times”16) Are employees aware of how to touch panel box doors ?(Required) YES NO Corrective ActionDuring training show employee how to touch a panel door and explain if wire becomes loose in panel it could cause a shock when touching door.Electric Receptacles17) Are the proper receptacles installed in wet locations?(Required) YES NO N/A Corrective ActionAny receptacle in a wet location must be protected by a GFCI breaker or circuit breaker.18). Are there any receptacles have missing or broken covers?(Required) YES NO Corrective ActionAny broken cover plates on a receptacle should be replaced. A broken plate could expose the wires within.Ground Fault Circuit Interrupter19). Are receptacles within 6 feet of wet areas protected by a GFCI unit?(Required) YES NO Testing RecordLocationFunctioned correctly Add RemoveOne record for each unitCorrective ActionAny receptacle within 6 feet of a wet source should be a GFCI unit. A GFCI unit should be installed.20) . Have any GFCI units within a panel box tested within the last months?(Required) YES NO Testing RecordLocationFunctioned CorrectlyCorrective Action, if needed Add RemoveCorrective ActionAny breaker within 6 feet of a wet source should be a GFCI unit. A GFCI breaker should be installed.Appliances21). Are there any exposed wires on electric appliances ?(Required) YES NO Corrective ActionThe appliance should either be replaced or the wire replaced.22). Do all appliances have a means of disconnecting ?(Required) YES NO Corrective ActionA switch should be installed on the appliance.23). Do all appliances have the required name plate ?(Required) YES NO Corrective ActionThe name plate should be replaced or the appliance replaced.Tripping Hazards24). Are there any extension cords across floor area where someone could trip ?(Required) YES NO Corrective ActionThe cords should be either routed, placed in cord savers, taped to floor on a temporary basis or an outlet installed to prevent hazard.Do you have any additional information about the Basic Electric Safety Program.This field is hidden when viewing the formCourse NameThis field is hidden when viewing the formType of Inspection
