Safety Compliance Checklist Template - Free Download | Page 4
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EVALUATION
STANDARD
Off-Site Risks
Other Factors:
Notes: This section is not scored.
Score:
Abandoned vehicles
NIA
Sidewalk hazards (holes, cracking, etc.)
Trucks/bus idling
Rubbish
Pest infestation
Dead animals
Traffic/pedestrian hazards
Fire hazards
Hazardous materials
Others
Pest Management
Other Factors:
Notes:
Score:
Record keeping
Fly fans or screen doors
Staff trained
Posted approved pesticide list
Approved pesticides
Others
Prevention Programs (Safe School
Plan, Volume 1)
Other Factors:
Notes:
Score:
Discipline Code
Attendance Plan
Page 4 of 5
OEHS School Safety Compliance Checklist
SSCC Worksheet v. 2 September 2007
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Threshold Questions
YES
NO
Are off-site air emission sources affecting the school
Are off-site noise pollution sources affecting the school
Are there leaking transformers immediately adjacent to the school
Are industrial facilities adjacent or in close proximity to the school [Please note facility location, type of operations, and business
name (if known).]
Are there multi-story buildings adjacent to the school
Threshold Questions
YES
NO
Is the site free of evidence of continuing pest infestation
Is a copy of the District's IPM Handbook kept in designated location and readily available
Are the necessary annual and 72-hour notifications of pesticide use provided (Review available documentation.]
Threshold Questions
YES
NO
Is ''Safe School Plan, Volume 1 - Prevention Programs'' readily available
Is the Safe School Plan up-to-date [Plans must be revised on or before October 1st of each school year.]
Was a completed plan, with all components, submitted to the Local District Operations Coordinator on or before the required date of
October 31st of the current school year
Is there documentation that the plan was discussed with staff this year
source: achieve.lausd.net
