Trainee Name____________________________

Trainee Social Security Number: ___________

Trainee Status:  _______

Course Name: ___________________

Course Code: ___________________                                 

National Center Course Number: ___________

Date Course Completed: ____________________

Performance Criteria Completed:  _____________

Performance Objectives:

                                                                                                                    Pass     Fail                  

Topic 1: Preventing Accidents

1.1   Describe causes of on-the-job accidents.

1.2   Explain how good housekeeping can prevent accidents.

1.3   Explain why it is important to follow all company safety
 policies.

1.4   Explain why it is important to report all on-the-job injuries,
 accidents, and near misses.

1.5   Explain why it is important to know and follow company
 evacuation procedures.

Topic 2: Work Site Safety 

2.1  Describe typical personal protection equipment, and
       explain when and why each type of equipment is used.

2.2  Describe how to inspect and care for personal protection
       equipment.

2.3  Describe a safe procedure for lifting heavy objects.

2.4  Describe common workplace hazards.

2.5  Describe rules and guidelines for general work site safety.

2.6   Describe safety requirements for working in confined spaces.

2.7   Describe safe practices for operating a motorized vehicle.

2.8   Describe safe lockout/tagout procedures.

2.9   Describe safe practices for working around barriers and
        barricades.

2.10 State the purpose of the OSHA Hazard Communication
        Standard and the function of Material Safety Data Sheets.

2.11 Describe rules and guidelines for working safely around
        hazardous substances.

2.12 Describe how to inspect and work safely with ladders.

2.13 Describe how to inspect and work safely with scaffolds.

Topic 3: Electrical and Fire Safety

3.1      Describe typical work site electrical hazards.

3.2      Describe safe practices for working around electrical
hazards.

3.3      Describe actions that should be taken when an electrical 
shock occurs.

3.4      Explain how fires start.

3.5      Describe common fire prevention practices.

3.6      Identify the classes of fires and the type of extinguisher
to use for each class.

3.7   Describe actions that should be taken when a fire occurs.

Performance Evaluator’s Signature _______________________________

Performance Evaluator’s Name (Print) ____________________________

Date Completed: _____________________________________________