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Metro Home Building Centre – Staff
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    • Section 02
      • Disciplinary Warning Notice Form
      • Manager Safety Performance Review
      • Supervisor Safety Performance Review
      • Employee Safety Performance Review
    • Section 04
      • Bomb Threat / Anonymous Telephone Call Record
      • Fall Arrest System Inspection Form
      • Emergency Response Plan for Employees Requiring Accommodations
      • Harassment Incident Report Form
      • Hazard Report Form
      • Hot Work Permit
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      • Non-Routine Work Form
      • Violence Incident Report Form
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    • Section 05
      • Annual Safety Committee Meeting Schedule
      • Safety Committee Meeting Minutes
      • Safety Committees Recommendations to Employer Form
    • Section 06
      • Orientation Checklist
      • Employee Information Form
      • Direct Deposit Agreement Form
      • TD1 – Personal Tax Credits Return
    • Section 07
      • First Aid Treatment Record
      • Refusal of Treatment or Refusal to be Transported to The Hospital Statement
    • Section 08
      • Ladder Inspection Checklist
      • Quarterly Workplace Inspection Checklist
      • Workplace Inspection Report Form
    • Section 10
      • Accident / Incident Investigation Report
      • Accident / Incident Investigation Employee’s Statement
      • Accident / Incident Investigation Witness Statement
    • Section 12
      • Return to Work Plan Monitoring Form
      • Exit Program Form – Injury Management and Return to Work
      • Return to Work Plan
  • Benefits
  • Online Training
  • Metro Home
  • Staff Home
  • Safety
    • Policies
    • Government Regulations
    • Meeting Minutes
    • Inspection Reports
    • Inspection Certificates
    • Guides
    • Posters
    • Responsibilities
  • Vacation Tracker
  • Vacation Board
  • Forms
    • Section 02
      • Disciplinary Warning Notice Form
      • Manager Safety Performance Review
      • Supervisor Safety Performance Review
      • Employee Safety Performance Review
    • Section 04
      • Bomb Threat / Anonymous Telephone Call Record
      • Fall Arrest System Inspection Form
      • Emergency Response Plan for Employees Requiring Accommodations
      • Harassment Incident Report Form
      • Hazard Report Form
      • Hot Work Permit
      • Housekeeping Inspection Form
      • Illness/Injury Reporting Form
      • Lockout Add
      • Lockout Removal
      • Non-Routine Work Form
      • Violence Incident Report Form
      • Work Refusal Form
      • Spill Report Form
    • Section 05
      • Annual Safety Committee Meeting Schedule
      • Safety Committee Meeting Minutes
      • Safety Committees Recommendations to Employer Form
    • Section 06
      • Orientation Checklist
      • Employee Information Form
      • Direct Deposit Agreement Form
      • TD1 – Personal Tax Credits Return
    • Section 07
      • First Aid Treatment Record
      • Refusal of Treatment or Refusal to be Transported to The Hospital Statement
    • Section 08
      • Ladder Inspection Checklist
      • Quarterly Workplace Inspection Checklist
      • Workplace Inspection Report Form
    • Section 10
      • Accident / Incident Investigation Report
      • Accident / Incident Investigation Employee’s Statement
      • Accident / Incident Investigation Witness Statement
    • Section 12
      • Return to Work Plan Monitoring Form
      • Exit Program Form – Injury Management and Return to Work
      • Return to Work Plan
  • Benefits
  • Online Training

Employee Safety Performance Review

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Employee Safety Performance Review Form

To be completed with Employee and Evaluator preset.
Employee Name
Date
Review Performed By

A. Safety Performance
Legend 5 – Outstanding The employee consistently exceeded job expectation during the past year 4 – Very Good The employee fully met and often exceeded job expectations during the past year 3 – Good The employee fully met job expectations during the past year 2 – Reasonable The employee met some but not all job expectations during the past year 1 – Unacceptable The employee did not meet job expectations during the past year

Select the rating that is consistent with previous year’s performance. Using Section C – Safety Performance Summary, explain in words how rating was achieved.
Evacuation Plan
can explain the different plans and actions to be taken, identify roles and functions, know location of master plans, emergency contact information, exit routes, assembly points and can properly name location of emergency equipment
WHMIS
can properly identify and explain 2 WHMIS symbols
(M)SDS
(M)SDS – can explain where (M)SDS sheets are kept and how to read a sheet
First aid
First aid – is able to name a first aid attendant working on their shift
Accident incident / investigations
can explain their role in reporting injuries
Hazard recognition
can explain their responsibility in hazard reporting
Return to work program
able to describe what their duties are for the RTW program
Safety training
all training has been completed per the training profile identified for current year. Documentation is required to validate the training
Safety leadership / leading by example
has successfully lead safety through example i.e. good housekeeping practices, proper lifting techniques, safe working habits directly related to their job

B. Personal Safety Performance

1. Has the employee received disciplinary action for a health and safety violation during previous year? If yes, please explain:
2. Has the employee reported any personal accidents or injuries during previous year? If yes, please explain:
Summary of performance—Summary of accomplishments and how results were achieved, including results against established workplan. Includes comments for rating based on above safety targets.
Overall Safety Performance Rating
The safety workplan ensures alignment between individual’s performance action plan and the business needs of the firm. This includes the development of safety skills, training, and competencies.
Name of Employee:(Required)
Date(Required)
Name of Evaluator:(Required)
Date(Required)
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