AF IMT Form 55 Employee Safety and Health Record

Form 55 is a U.S. Air Force form also known as the "Employee Safety And Health Record". The latest edition of the form was released in November 1, 1996 and is available for digital filing.

Download an up-to-date Form 55 in PDF-format down below or look it up on the U.S. Air Force Forms website.

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EMPLOYEE SAFETY AND HEALTH RECORD
The AF Form 55 will be maintained by the supervisor in the work place. For Department of the Air Force civilian personnel, this form may be filed with
AF Form 971, Supervisor's Employee Brief. For military personnel - file with any records. See AFI 91-301.
1. NAME (Last, First, Middle Initial) GRADE
2. SSN
3. ORGANIZATION & OFC SYMBOL AND/OR WORKPLACE IDENTIFIER
5. DUTY TITLE
4. OCCUPATIONAL SERIES OR PRIMARY AFSC
6. HAZARDS ASSOCIATED WITH PRESENT JOB OR TASKS AND WORK AREAS (NOISE, ELECTRICAL SHOCK, RADIATION HAZARDOUS MATERIALS, ETC.)
7. OCCUPATIONAL HEALTH MEDICAL EXAMINATION (OHME) REQUIRED
I MANDATORY ITEMS (To be briefed to all personnel, as applicable)
1. HAZARDS OF THE JOB OR TASKS, AND SAFETY PROCEDURES TO BE FOLLOWED (See Item 6)
2. HAZARDS OF THE WORK AREAS (See Item 6)
3. OSH STANDARDS AND GUIDANCE THAT APPLY TO JOB AND WORK PLACE
4. PERSONAL PROTECTIVE EQUIPMENT THEY WILL NEED AND HOW, WHEN, AND WHERE TO USE IT (To be entered into Sections II and III of this form)
5. LOCATION AND USE OF EMERGENCY AND FIRE PROTECTION EQUIPMENT
6. EMERGENCY PROCEDURES THAT APPLY TO THEIR JOB AND WORK PLACE
7. REPORTING UNSAFE EQUIPMENT, CONDITIONS OR PROCEDURES TO SUPERVISOR IMMEDIATELY
8. LOCATION, SUBMITTING PROCEDURES, AND PURPOSE OF AF FORM 457, USAF HAZARD REPORT (AFI 91-202)
9. MISHAP REPORTING PROCEDURES (AFI 91-204)
10. EMERGENCY TELEPHONE NUMBERS
11. LOCATION AND REQUIRED REVIEW OF APPROPRIATE SAFETY BULLETIN BOARDS, AF VISUAL AIR 91-307
12. LOCATION OF MEDICAL FACILITIES AND PROCEDURES FOR OBTAINING TREATMENT
13. REQUIREMENTS FOR DOCUMENTATION AND NOTIFICATION OF ON-THE-JOB INJURY OR ILLNESS
14. PURPOSE AND FUNCTION OF THE AF FORM 1118, NOTICE OF HAZARD
15. INDIVIDUAL RESPONSIBILITIES FOR ENSURING OWN SAFETY
16. REQUIRED USE OF SAFETY BELTS
17 PERSONNEL RIGHTS (AFI 91-301)
18. AIR FORCE HAZARD COMMUNICATION PROGRAM REQUIREMENTS
19. CONFINED SPACE REQUIREMENTS, IF REQUIRED (AFOSH STANDARD 91-25)
20. MANUAL LIFTING GUIDANCE (AFOSH STANDARD 91-46)
21. JEWELRY SAFETY (AFOSH STANDARD 91-66)
22. POTENTIAL HAZARDS ASSOCIATED WITH THE SURROUNDING LOCAL AREA (If operational activities require travel off installation)
23. OTHER (List in remarks or on continuation sheet, if necessary)
II PERSONAL PROTECTION ISSUED
III PERSONAL PROTECTION PROVIDED IN WORK AREA
1. FOOT PROTECTION
1. FOOT PROTECTION
2. ARM/HAND PROTECTION
2. ARM/HAND PROTECTION
3. EYE PROTECTION
3. EYE PROTECTION
4. HEARING PROTECTION
4. HEARING PROTECTION
5. RESPIRATORY PROTECTION
5. RESPIRATORY PROTECTION
6. HEAD PROTECTION
6. HEAD PROTECTION
7. OTHER (List)
7. OTHER (List)
PREVIOUS EDITION MAY BE USED
PAGE 1 OF 2 PAGES
AF IMT 55, 19961101, V3
EMPLOYEE SAFETY AND HEALTH RECORD
The AF Form 55 will be maintained by the supervisor in the work place. For Department of the Air Force civilian personnel, this form may be filed with
AF Form 971, Supervisor's Employee Brief. For military personnel - file with any records. See AFI 91-301.
1. NAME (Last, First, Middle Initial) GRADE
2. SSN
3. ORGANIZATION & OFC SYMBOL AND/OR WORKPLACE IDENTIFIER
5. DUTY TITLE
4. OCCUPATIONAL SERIES OR PRIMARY AFSC
6. HAZARDS ASSOCIATED WITH PRESENT JOB OR TASKS AND WORK AREAS (NOISE, ELECTRICAL SHOCK, RADIATION HAZARDOUS MATERIALS, ETC.)
7. OCCUPATIONAL HEALTH MEDICAL EXAMINATION (OHME) REQUIRED
I MANDATORY ITEMS (To be briefed to all personnel, as applicable)
1. HAZARDS OF THE JOB OR TASKS, AND SAFETY PROCEDURES TO BE FOLLOWED (See Item 6)
2. HAZARDS OF THE WORK AREAS (See Item 6)
3. OSH STANDARDS AND GUIDANCE THAT APPLY TO JOB AND WORK PLACE
4. PERSONAL PROTECTIVE EQUIPMENT THEY WILL NEED AND HOW, WHEN, AND WHERE TO USE IT (To be entered into Sections II and III of this form)
5. LOCATION AND USE OF EMERGENCY AND FIRE PROTECTION EQUIPMENT
6. EMERGENCY PROCEDURES THAT APPLY TO THEIR JOB AND WORK PLACE
7. REPORTING UNSAFE EQUIPMENT, CONDITIONS OR PROCEDURES TO SUPERVISOR IMMEDIATELY
8. LOCATION, SUBMITTING PROCEDURES, AND PURPOSE OF AF FORM 457, USAF HAZARD REPORT (AFI 91-202)
9. MISHAP REPORTING PROCEDURES (AFI 91-204)
10. EMERGENCY TELEPHONE NUMBERS
11. LOCATION AND REQUIRED REVIEW OF APPROPRIATE SAFETY BULLETIN BOARDS, AF VISUAL AIR 91-307
12. LOCATION OF MEDICAL FACILITIES AND PROCEDURES FOR OBTAINING TREATMENT
13. REQUIREMENTS FOR DOCUMENTATION AND NOTIFICATION OF ON-THE-JOB INJURY OR ILLNESS
14. PURPOSE AND FUNCTION OF THE AF FORM 1118, NOTICE OF HAZARD
15. INDIVIDUAL RESPONSIBILITIES FOR ENSURING OWN SAFETY
16. REQUIRED USE OF SAFETY BELTS
17 PERSONNEL RIGHTS (AFI 91-301)
18. AIR FORCE HAZARD COMMUNICATION PROGRAM REQUIREMENTS
19. CONFINED SPACE REQUIREMENTS, IF REQUIRED (AFOSH STANDARD 91-25)
20. MANUAL LIFTING GUIDANCE (AFOSH STANDARD 91-46)
21. JEWELRY SAFETY (AFOSH STANDARD 91-66)
22. POTENTIAL HAZARDS ASSOCIATED WITH THE SURROUNDING LOCAL AREA (If operational activities require travel off installation)
23. OTHER (List in remarks or on continuation sheet, if necessary)
II PERSONAL PROTECTION ISSUED
III PERSONAL PROTECTION PROVIDED IN WORK AREA
1. FOOT PROTECTION
1. FOOT PROTECTION
2. ARM/HAND PROTECTION
2. ARM/HAND PROTECTION
3. EYE PROTECTION
3. EYE PROTECTION
4. HEARING PROTECTION
4. HEARING PROTECTION
5. RESPIRATORY PROTECTION
5. RESPIRATORY PROTECTION
6. HEAD PROTECTION
6. HEAD PROTECTION
7. OTHER (List)
7. OTHER (List)
PREVIOUS EDITION MAY BE USED
PAGE 1 OF 2 PAGES
AF IMT 55, 19961101, V3

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