SAMPLE Templates and Checklists

Lapse in Appropriations

For workplace safety and health, please call 800-321-6742; for mine safety and health, please call 800-746-1553; for Job Corps, please call 800-733-5627 and for Wage and Hour, please call 1-866-487-9243 (1 866-4-US-WAGE).  This website is currently not being updated due to the suspension of Federal government services. The last update to the site was 10/1/2025.  Updates to the site will start again when the Federal government resumes operations.

The sample templates and checklists listed on this page were provided by stakeholders to assist others in complying with MSHA’s working place exam rule for metal and nonmetal mines. If you wish to submit other samples of templates or checklists or similar compliance aids for MSHA review and potential posting, please send your materials to:

Don Vickers
Metal and Nonmetal Safety Division
vickers.donald@dol.gov

SAMPLE 1 model workplace exam form requirements only

SAMPLE 2a Examination of Working Places DEMO (4.0)

SAMPLE 2b Examination of Working Places DEMO (4.0) SAMPLE

SAMPLE 3 CRUSHER SCREEN DAILY INSP

SAMPLE 4 Workplace Exam Record Form

SAMPLE 5 Workplace Exam Record Form C