1D Revised 07/26/19
STATE OF DELAWARE
WORKPLACE SAFETY PROGRAM QUESTIONNAIRE – PART II
Please submit your application five months prior to your policy renewal date.
Remember to include your inspection fee when mailing.
JOB SITE ADDENDUM
*Please include General Application with submission
Business Name: ___________________________________________________________________________
I. SAFETY EQUIPMENT/PROTECTIVE CLOTHING AND EQUIPMENT N/A
This section deals with protective clothing necessary for the job or jobs performed.
1. List Personal Protective Equipment (PPE) for your industry:
a.) How do you enforce? ___________________________________________________________
b.) How is PPE maintained? ________________________________________________________
c.) Is equipment subsidized? ☐ Partially ☐ Fully ☐ Not at all
II. EYE PROTECTION N/A
You should complete this section whenever employees are exposed to such hazards as chemical fumes,
vapors, splashes, intense heat, molten metals, wood and metal chips, and high dust levels.
1. Are safety glasses worn which meet or exceed ANSI standards? ☐ Yes ☐ No
a) Do they have side shields? ☐ Yes ☐ No
b) Are goggles worn when they are needed? ☐ Yes ☐ No
c) Are all glasses regularly cleaned after each use, particularly the goggles? ☐ Yes ☐ No
2. Are safety shields worn over safety glasses (for protection against chemical
splash, glass breakage & severe impact hazards)? ☐ Yes ☐ No
3. Are there eye or eye/face wash stations in areas where chemicals are handled? ☐ Yes ☐ No
III. HEARING PROTECTION N/A
Complete this section if your business has a DBA level of 85 or more.
1. Do you have a hearing conservation program? ☐ Yes ☐ No
a) Do you comply with all OSHA or Delaware state standards where
employees are exposed on a regular basis to high noise levels? ☐ Yes ☐ No
b) How and when are workplace noise levels monitored? _______________________________
c) Do you give your employees annual hearing tests, with records maintained? ☐ Yes ☐ No
d) Is proper hearing protection (ear muffs or plugs) furnished and/or required
to be worn? ☐ Yes ☐ No
e) How is this enforced? _________________________________________________________