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Cultura Documentos
EMPRESA:
RAZO SOCIAL:____ _______________________________________________________
NOME DE FANTASIA:_________________________________________________________
CNPJ/CGC___________________________CNAE:_____________GRAU DE RISCO:______
RUA/AV._______________________________________________BAIRRO:______________
CIDADE :
FONE :
E-MAIL:_____________________________________________________________________
QUANTIFICAO DE EMPREGADOS :
homens maiores de 45 anos :
______
______
______
______
_______
ano
ms
ano
ano
ano
ano
com
_________________ / __________ :
ms
ano
ano
_________________ / __________ :
ms
ano
_________________ / __________ :
ms
ano
SETOR :____________________________________________
ATENO! Esta seo do checklist deve ser aplicada, em separado, para cada
setor da empresa.
1 - RUDO CONTNUO (Anexo n 1 da NR-15 da Portaria 3214/78)
(
6 _____________________________
2________________________________
7 _____________________________
3________________________________
8 _____________________________
4________________________________
9 _____________________________
5________________________________
10_____________________________
3 _____________________________
4 _____________________________
Ventilao :
Natural:___________________________________________________________
___________________________________________________________
artificial : __________________________________________________________
__________________________________________________________
(
1________________________________
3 ____________________________
2________________________________
4 ____________________________
2 _____________________________
3 _____________________________
2________________________________
4 _____________________________
3 _____________________________
2________________________________
4 _____________________________
2 _____________________________
Temperatura :
por _____________________________
2________________________________
por _____________________________
Agente
_________________________________
2________________________________
_________________________________
3________________________________
_________________________________
4________________________________
_________________________________
5________________________________
_________________________________
6________________________________
_________________________________
7________________________________
_________________________________
5
8________________________________
_________________________________
9________________________________
_________________________________
10_______________________________
_________________________________
Agente
1________________________________
_________________________________
2________________________________
_________________________________
2________________________________
_________________________________
3________________________________
_________________________________
) h reas de risco :
Posto de trabalho
Agente
1________________________________
_________________________________
2________________________________
_________________________________
B - INFLAMVEIS
(
) h reas de risco :
Posto de trabalho
Agente
1________________________________
_________________________________
2________________________________
_________________________________
C - ELETRICIDADE
(
) h reas de risco :
Posto de trabalho
Agente
1________________________________
_________________________________
2________________________________
_________________________________
D - RADIAO IONIZANTE
(
) h reas de risco :
Posto de trabalho
Agente
1________________________________
_________________________________
2________________________________
_________________________________
) no h.
) h
Posto de trabalho
Tipo de esforo
1________________________________
_________________________________
2________________________________
_________________________________
3________________________________
_________________________________
B - MOBILIRIO
Posto de trabalho
Mesa / bancada
Assentos
Comandos
1___________________
_____________
_________________
___________
2___________________
_____________
_________________
___________
3___________________
_____________
_________________
___________
4___________________
_____________
_________________
___________
5___________________
_____________
_________________
___________
C - EQUIPAMENTOS DE TRABALHO
Posto de trabalho
Equipamento
Postura
Esforo fsico
1___________________
_____________
_________________
___________
2___________________
_____________
_________________
___________
3___________________
_____________
_________________
___________
4___________________
_____________
_________________
___________
5___________________
_____________
_________________
___________
D - VENTILAO
[ ver item calor ]
(
) ambiente agradvel.
) abafado
E - ILUMINAO
Aparentemente
) satisfatrio
Portas/janelas/aberturas/telhas
) insuficiente
rea
1________________________________
_________________________________
2________________________________
_________________________________
3________________________________
_________________________________
4________________________________
_________________________________
5________________________________
_________________________________
F - RUDO
8
) confortvel
) desconfortvel
G - ORGANIZAO DO TRABALHO
- normas de produo : ________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
- o modo operatrio : __________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
- a exigncia de tempo : _______________________________________________________
____________________________________________________________________________
____________________________________________________________________________
- a determinao do contedo de tempo : ___________________________________________
____________________________________________________________________________
____________________________________________________________________________
- o ritmo de trabalho : __________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
- o contedo das tarefas : _______________________________________________________
____________________________________________________________________________
____________________________________________________________________________
- o sistema de avaliao : _______________________________________________________
____________________________________________________________________________
____________________________________________________________________________
) alvenaria
) outro _______________________________________________
P direito : __________metros
Pisos : __________________________________________
( ) Fiao toda embutida em eletrodutos, com quadros de distribuio protegidos com tampas,
caixas individuais de chave geral para cada mquina com disjuntor magntico individual, com
protees contra contatos acidentais, devidamente sinalizadas, com tomadas de fora de
dimensionamento e nmero adequados, destinadas uma para cada equipamento.
(
) Se no, descrio :
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Mquinas / equipamentos eltricos
Aterramento : _________________________________________________________________
Manuteno Eltrica : __________________________________________________________
____________________________________________________________________________
) no h.
) h
Pronturio :
Projeto Mecnico: __________________________________________________
Projeto Civil da Casa de Caldeira : _____________________________________
Projeto de Instalao : _______________________________________________
Relatrio Anual de Inspeo : ( ultimo ) -
Teste Hidrosttico :
( ultimo ) -
Caldeira :
Placa de Identificao : _____________________________________________
Indicao de Categoria : _____________________________________________
Manual de Operao :
_____________________________________________
_______________________________________
numero : _________
qualificao : ________________________________
11
____________________________________________________________________________
) no h.
) h
Pronturio :
Projeto Mecnico: __________________________________________________
Projeto de Instalao : _______________________________________________
Relatrio Anual de Inspeo : ( ultimo ) -
Teste Hidrosttico :
( ultimo ) -
Caldeira :
Placa de Identificao : _____________________________________________
Indicao de Categoria : _____________________________________________
Manual de Operao :
_____________________________________________
_______________________________________
numero : _________
qualificao : ________________________________
____________________________________________________________________________
) no h.
) h
____________________________________________________________________________
____________________________________________________________________________
) no h.
) h
gua - Gs :
PQS
: _________________
__________________________
Gs Carbnico : _________________________
Sinalizao : ____________________________________________________________
______________________________________________________________________
Distncia :______________________________________________________________
Etiquetas de Identificao : _______________________________________________
_______________________________________________________________________
Fichas de Controle de Inspeo : ____________________________________________
_______________________________________________________________________
Hidrantes : __________________________________________________________________
13
feminino
nmero de gabinetes :
___________________
_______________
nmero de lavatrios :
___________________
rea
___________________
_______________
paredes
___________________
_______________
pisos
___________________
_______________
limpeza
___________________
_______________
_______________
banheiros :
masculino
feminino
nmero de chuveiros :
_____________________
________________
rea
_____________________
________________
paredes
_____________________
________________
pisos
_____________________
________________
limpeza
_____________________
________________
vestirios :
masculino
feminino
nmero
_________________________
________________
rea
_________________________
________________
paredes
_________________________
________________
pisos
_________________________
________________
nmero de armrios :
_________________________
________________
limpeza
_________________________
________________
locais de refeio :
Local de Instalao :
___________________________________________________
Mesas e Assentos
___________________________________________________
Pisos
___________________________________________________
Iluminao
___________________________________________________
14
Ventilao
___________________________________________________
Lavatrios
___________________________________________________
Pias
____________________________________________________
gua Potvel
___________________________________________________
Aquecimento de refeies :
______________________________________________
cozinha : ___________________________________________________________________
____________________________________________________________________________
alojamentos :
______________________________________________________________
____________________________________________________________________________
gua potvel :
____________________________________________________________________________
____________________________________________________________________________
rea de lazer :
____________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Lquidos : __________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
15
____________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Rotulagem Preventiva : ______________________________________________________
____________________________________________________________________________
____________________________________________________________________________
) Irregular.
) Irregular.
Iniciais
Descrio
1-
_______
___________________________________________
2-
_______
___________________________________________
3-
_______
___________________________________________
4-
_______
___________________________________________
5-
_______
___________________________________________
6-
_______
___________________________________________
7-
_______
___________________________________________
16
8-
_______
___________________________________________
9-
_______
___________________________________________
10 -
_______ *
___________________________________________
11 -
_______ *
___________________________________________
12 -
_______ *
___________________________________________
13 -
_______ *
___________________________________________
14 -
_______ *
___________________________________________
15 -
_______ *
___________________________________________
16 -
_______ *
___________________________________________
17 -
_______ *
___________________________________________
18 -
_______ *
___________________________________________
19 -
_______ *
___________________________________________
20 -
_______ *
___________________________________________
22 -
_______ *
___________________________________________
23 -
_______ *
___________________________________________
24 -
_______ *
___________________________________________
25 -
_______ *
___________________________________________
26 -
_______ *
___________________________________________
29.
Medida
1 - _______________________
___________________________________________
2 - _______________________
___________________________________________
3 - _______________________
___________________________________________
4 - _______________________
___________________________________________
5 - _______________________
___________________________________________
6 - _______________________
___________________________________________
17
7 - _______________________
__________________________________________
8 - _______________________
___________________________________________
9 - _______________________
___________________________________________
10 - _______________________
___________________________________________
ESTABELECIMENTO DE PRIORIDADES
E METAS DE AVALIAO E CONTROLE
PROVIDNCIA
SETOR
12345678910-
18
EPI
RESPONSVEL TCNICO
NOME:__________________________________________________
CRM / CREA ________________ RG MTb-SSMT ____._________
19
CA