You are on page 1of 7

Safety Training Needs Assessment Form

Instructions: Please review each question and either check YES or NO. If a question is checked YES you will be required to complete the training
topic before initial assignment of job task. Please discuss with your supervisor and have him/her sign the form. Please review the EH&S website for
registration information.

Safety Training Needs Assessment Department:

Employee Name (Print): Employee (Signature):

Supervisor Name: Supervisor (Signature): Date:


Read and answer each question. If answer is Answer
yes, see middle column for training, right Training Required/Optional, Frequency
column for frequency of training.
Yes Departmental Safety Checklist & New Employee
No Orientation (NEO) REQUIRED TRAINING: Initial
Do you receive a paycheck from UNC Supervisor safety hazard and safe operating
Charlotte (regardless if you are a procedure discussion. REGISTRATION: Attend New Employee
student worker or full/part time Accident Prevention, Investigation and Reporting Orientation (NEO) sponsored by Human
employee)? Back Safety and Injury Prevention Resources Department or complete Skillport
Building Emergency Evacuation Plan online modules
Fire Safety and Prevention Duration: 2-4 hours
Slips, Trips, Falls
Yes REQUIRED TRAINING: Periodic.
Do you operate scissor lifts, man lifts or No Aerial Lift Training REGISTRATION: EH&S.
other aerial elevating platforms?
Duration: 2-4 hours
Yes REQUIRED TRAINING: Periodic.
Are you an employee of the University? No Accident Reporting and Investigation REGISTRATION: NEO or Skillport
Duration: 1 hours
Do you work for maintenance, custodial, Yes REQUIRED TRAINING: Annual.
or facility operations AND disturb No REGISTRATION: EH&S
Asbestos Awareness
asbestos? Duration: 1 hours

Does your work require you to lift heavy Yes REQUIRED TRAINING: Periodic.
objects or repeatedly move or carry No Back Safety and Injury Prevention REGISTRATION: NEO or Skillport
items throughout the day? Duration: 1 hours

J:\Safety\ap-bg\Safety Training\Training website Content 2011\Safety Training Needs Assessment 2011.docx 11/2011 Page 1 of 7
Safety Training Needs Assessment Department:

Employee Name (Print): Employee (Signature):

Supervisor Name: Supervisor (Signature): Date:


Read and answer each question. If answer is Answer
yes, see middle column for training, right Training Required/Optional, Frequency
column for frequency of training.
Yes REQUIRED TRAINING: Periodic.
Do you supervisor employees or No Behavior-Based Safety for Supervisors REGISTRATION: Skillport Online
students?
Duration: 1 hours

Do you work with potentially infectious Yes REQUIRED TRAINING: Annual


body fluids? No Bloodborne Pathogen (BBP) Training REGISTRATION: EH&S
Duration: 1-2 hours.
Yes REQUIRED TRAINING: Annual
Do you work in a building or have the No Building Emergency Evacuation REGISTRATION: NEO and EH&S
potential to be in a building?
Duration: 1 hours
Yes REQUIRED TRAINING: Every 2 yrs.
Do you work in a laboratory with No Chemical Hygiene Plan REGISTRATION: EH&S
exposure to chemicals?
Duration: 1 hours
Yes REQUIRED TRAINING: Periodic
Do you work with compressed gas No Compressed Gas Cylinder REGISTRATION: Skillport and EH&S
cylinders?
Duration: 1 hours
Yes REQUIRED TRAINING: Periodic
Do you work at a computer workstation No Computer Ergonomics REGISTRATION: Skillport and EH&S
for four (4) consecutive hours daily?
Duration: 1 hours
Yes REQUIRED TRAINING: Periodic
Do you work or oversee work in No Confined Space REGISTRATION: EH&S
manholes or other confined spaces?
Duration: 2-4 hours
Yes REQUIRED TRAINING: Periodic
Do you operate university owned No Defensive Driving Fundamentals REGISTRATION: Skillport Online
vehicles?
Duration: 1-2 hours

Do you spend long periods of time Yes REQUIRED TRAINING: Periodic


performing the same task? No Ergonomics in the Workplace REGISTRATION: Skillport Online
Duration: 1-2 hours

J:\Safety\ap-bg\Safety Training\Training website Content 2011\Safety Training Needs Assessment 2011.docx 11/2011 Page 2 of 7
Safety Training Needs Assessment Department:

Employee Name (Print): Employee (Signature):

Supervisor Name: Supervisor (Signature): Date:


Read and answer each question. If answer is Answer
yes, see middle column for training, right Training Required/Optional, Frequency
column for frequency of training.
Yes REQUIRED TRAINING: Periodic
No REGISTRATION: Skillport Online
Do you plug in electrical use devices? Electrical Safety Awareness
Duration: 0.5 hours

Yes REQUIRED TRAINING: Periodic


Are you qualified to perform low voltage No Electrical Safety Low Voltage REGISTRATION: EH&S
electrical work?
Duration: 2-4 hours
Yes REQUIRED TRAINING: Periodic
Are you qualified to perform Medium No Electrical Safety Medium/High Voltage REGISTRATION: EH&S
Voltage electrical work?
Duration: 2-4 hours
Yes REQUIRED TRAINING: Periodic
Do you work in or around trenches ore No Excavation and Trenching REGISTRATION: EH&S
excavations?
Duration: 2-4 hours

Do you work at heights above six feet Yes REQUIRED TRAINING: Periodic
exposed to fall hazards? No Fall Protection and Elevated Work REGISTRATION: EH&S
Duration: 2-4 hours
Yes REQUIRED TRAINING: Annual
Are you required to use a fire No Fire Extinguisher REGISTRATION: EH&S & 49er Online
extinguisher in an emergency?
Duration: 1-2hours
Yes REQUIRED TRAINING: Periodic
Are you exposed to fire safety hazards? No Fire Safety and Prevention REGISTRATION: Skillport Online
Duration: 1 hour
Yes REQUIRED TRAINING: Every 3 yrs.
Do you operate a forklift or motorized No Forklift (Powered Industrial Truck REGISTRATION: EH&S
pallet jack?
Duration: 2-4 hours
Yes REQUIRED TRAINING: Periodic
Do you operate a golf cart? No Golf Cart Service Vehicle REGISTRATION: EH&S & Supervisor
Duration: 2-4 hours

J:\Safety\ap-bg\Safety Training\Training website Content 2011\Safety Training Needs Assessment 2011.docx 11/2011 Page 3 of 7
Safety Training Needs Assessment Department:

Employee Name (Print): Employee (Signature):

Supervisor Name: Supervisor (Signature): Date:


Read and answer each question. If answer is Answer
yes, see middle column for training, right Training Required/Optional, Frequency
column for frequency of training.
Yes REQUIRED TRAINING: Periodic
Do you work with power tools? No Hand and Power Tool Safety REGISTRATION: Skillport Online
Duration: 1 hour
Yes REQUIRED TRAINING: Periodic
Do you use hazardous chemicals as No Hazard Communication REGISTRATION: EH&S
part of your job?
Duration: 1 hour
Yes REQUIRED TRAINING: Periodic
Do you handle drums or other No Hazardous Materials Handling and Storage REGISTRATION: Skillport Online
hazardous storage materials?
Duration: 1 hour

Do you need to dispose of hazardous Yes REQUIRED TRAINING: Periodic


chemicals or work in satellite No Hazardous Waste Management REGISTRATION: EH&S & 49er Online
accumulation area? Duration: 1 hour
Do you work in an environment with Yes
excessive noise (exposure to noise No REQUIRED TRAINING: Annual
greater than 85 dB over an 8-hour time- Hearing Conservation REGISTRATION: EH&S
weighted average)? Duration: 1-2 hours

Yes REQUIRED TRAINING: Periodic


Do you work in elevated temperature No Heat Stress Recognition REGISTRATION: Skillport Online
environments?
Duration: 1 hour
Yes REQUIRED TRAINING: Periodic
Do you work in a laboratory? No Laboratory Safety REGISTRATION: Skillport Online
Duration: 1 hour
Yes REQUIRED TRAINING: Periodic
Do you use ladders? No Ladder Safety REGISTRATION: EH&S & Supervisor
Duration: 1 hour

J:\Safety\ap-bg\Safety Training\Training website Content 2011\Safety Training Needs Assessment 2011.docx 11/2011 Page 4 of 7
Safety Training Needs Assessment Department:

Employee Name (Print): Employee (Signature):

Supervisor Name: Supervisor (Signature): Date:


Read and answer each question. If answer is Answer
yes, see middle column for training, right Training Required/Optional, Frequency
column for frequency of training.
Yes REQUIRED TRAINING: Periodic
Do you use class1-4 lasers? No Laser Safety REGISTRATION: Skillport Online
Duration: 1 hour

Do you work in environments removing Yes REQUIRED TRAINING: Periodic


paint or other areas where lead could be No Lead Awareness REGISTRATION: Skillport Online
present? Duration: 1 hour
Do you repair, inspect, adjust, install, Yes REQUIRED TRAINING: Periodic
service, or clean machinery or No Lockout/Tagout REGISTRATION: EH&S
equipment?
Duration: 2-4 hours
Yes REQUIRED TRAINING: Periodic
Do you work with drill press, saws or No Machine Guarding REGISTRATION: EH&S
other equipment?
Duration: 1-2 hours
Yes REQUIRED TRAINING: Periodic
Do you work in a moldy or mildew No Mold Awareness REGISTRATION: Skillport Online
environment?
Duration: 1 hour
Yes REQUIRED TRAINING: Periodic
Do you spend 2 or more consecutive in No Office Safety REGISTRATION: EH&S
office environment?
Duration: 1 hour
Yes REQUIRED TRAINING: Periodic
Do you wear gloves, hard hats, safety No Personal Protective Equipment (PPE) REGISTRATION: EH&S & Supervisors
glasses, goggles, body harness, etc.?
Duration: 1-2 hours
Yes REQUIRED TRAINING: Periodic
Do you work with radioactive materials? No Radiation Safety for Authorized Users REGISTRATION: EH&S & 49er Online
Duration: 2-4 hours
Yes REQUIRED TRAINING: Periodic
Do you work with non-ionizing radiation No Radiation Safety Non-Ionizing REGISTRATION: Skillport Online
(lasers, microwaves, etc.)?
Duration: 1 hour

J:\Safety\ap-bg\Safety Training\Training website Content 2011\Safety Training Needs Assessment 2011.docx 11/2011 Page 5 of 7
Safety Training Needs Assessment Department:

Employee Name (Print): Employee (Signature):

Supervisor Name: Supervisor (Signature): Date:


Read and answer each question. If answer is Answer
yes, see middle column for training, right Training Required/Optional, Frequency
column for frequency of training.
Do you work in an area where Yes REQUIRED TRAINING: Annual
exposures of nuisance dust, silica, No Respiratory Protection REGISTRATION: EH&S
require respirator use?
Duration: 1-2 hours
Yes REQUIRED TRAINING: Periodic
Do you erect or work on scaffolds? No Scaffolds and Ladder Safety REGISTRATION: EH&S
Duration: 2-4 hours
Yes REQUIRED TRAINING: Periodic
Do you access building and grounds? No Slips, Trips, Falls REGISTRATION: Skillport Online
Duration: 1 hour
Yes REQUIRED TRAINING: Periodic
Do you do a lot of manual materials No Sprains and Strains REGISTRATION: Skillport Online
handling?
Duration: 1 hour

Are you required to remove light bulbs, Yes REQUIRED TRAINING: Periodic
motor oil, batteries, mercury containing No Universal Waste REGISTRATION: EH&S & 49er Online
devices? Duration: 1 hour
Yes REQUIRED TRAINING: Periodic
Do you operate a university van? No Van Certification REGISTRATION: EH&S
Duration: 2 hours
Yes REQUIRED TRAINING: Periodic
Do you perform welding, cutting or No Welding and Cutting Safety REGISTRATION: EH&S & Supervisor
brazing activities
Duration: 1-2 hours
Yes REQUIRED TRAINING: Periodic
Are you a supervisor? No Workers Compensation for Supervisors REGISTRATION: EH&S
Duration: 2-4 hours

J:\Safety\ap-bg\Safety Training\Training website Content 2011\Safety Training Needs Assessment 2011.docx 11/2011 Page 6 of 7
Safety Training Needs Assessment Department:

Employee Name (Print): Employee (Signature):

Supervisor Name: Supervisor (Signature): Date:


Read and answer each question. If answer is Answer
yes, see middle column for training, right Training Required/Optional, Frequency
column for frequency of training.
Yes REQUIRED TRAINING: Periodic
Do you work with X-ray producing
No REGISTRATION: EH&S
devices? X-Ray Safety Training
Duration: 2-4 hours
.
Yes REQUIRED TRAINING: Periodic
Do you ship dangerous goods or dry
No IATA/DOT Training (Shipment of Hazardous REGISTRATION: EH&S
ice?
Materials/Dangerous Goods) Duration: 2-4 hours

Yes REQUIRED TRAINING: Periodic


Do you supervise employees? No REGISTRATION: EH&S
EH&S Supervisor Development Training
Duration: 2-4 hours

Yes REQUIRED TRAINING: Periodic


Do you work with biological agents? No REGISTRATION: EH&S
Biosafety Training
Duration: 2-4 hours

Yes REQUIRED TRAINING: Periodic


Do you work with select agents? No REGISTRATION: EH&S
Select Agent Training
Duration: 2-4 hours

J:\Safety\ap-bg\Safety Training\Training website Content 2011\Safety Training Needs Assessment 2011.docx 11/2011 Page 7 of 7