ABC Company Supervisor Safety Performance Appraisal

ABC Company Supervisor Safety Performance Appraisal

Supervisor: Appraised By:

Date: Signature:

Performance is graded on a 1-5 number system, with the total indicating the individual's overall performance.

1 Does not meet expectations. 2 Low. Improvement Needed. 3 Average by minimum standards. 4 Above average. Does more than most. 5 Excellent.

1. Awareness and enforcement of company safety and health rules, policies and procedures. Disciplinary action administered equally and consistently.

1 2 3 4 5

Comments:

2. Conducts on-the-job safety education and training. Comments:

1 2 3 4 5

3. Safety orientation for all new/transferred employees and completes required documentation.

Comments:

1 2 3 4 5

4. Provides for and enforces the use of personal protective equipment (PPE) for the job duties that require it. Comments:

5. Maintains/inspects all equipment for safe, operable condition. Example: machine guarding is in place. Comments:

6. Promptness in reporting unsafe acts/conditions and requesting assistance to abate these conditions. Example: issuance of work orders, contacting safety director Comments:

7. Investigates all accidents, incidents and near-misses in a timely manner. Comments:

8. Completeness of accident forms. Comments:

1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

9. Cooperativeness. Willingness and ability to work with others to improve/support safety efforts.

Comments:

1 2 3 4 5

10. Dependability. Correcting identified hazards timely. Example: audits, work orders, employee safety concerns.

Comments:

1 2 3 4 5

11. Proactiveness. Recognizing and addressing hazardous conditions and unsafe acts before accident takes place.

Comments:

1 2 3 4 5

12. Overall department housekeeping. Comments:

1 2 3 4 5

TOTAL

12 to 20. Does not

meet expectations.

21 to 31. Improvement

required.

32 to 42. Average.

Needs improvement.

43 to 53. Above average.

54 to 60. Excellent.

Requested Accident Reduction Plan Number: _______

Evaluator Comments/Signature: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________

Supervisor Signature/Date: ________________________________

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