Acadian Contractors, Inc.

• Document Title

• Department Supervisor

EMPLOYEE INFORMATION

• Employee Name

• Last four digits of social security number

COMPANY INFORMATION

• Company

• Department

• Position

EVALUATION

• Date of Evaluation

  Date

• Evaluation conducted by:

RIGGING

• Does the employee perform overhead rigging duties

  Yes

  No

• Review the employee rigger card to ensure it is current.
  If not current advise that rigger duties are suspended and contact supervisor immediately

• Is the employee familiar with and capable of demonstrating proper hand signals

  Yes

  No

  N/A

• Can the employee demonstrate the proper method in which they would rig a load

  Yes

  No

  N/A

• Can the employee demonstrate a proper pre-use inspection of the rigging equipment

  Yes

  No

  N/A

• Is the employee able to identify rigging gear by name

  Yes

  No

  N/A

• Can the employee explain proper tag line usage and also restrictions in regards to tag lines?

  Yes

  No

  N/A

• Are you able to witness tag lines being used properly? (Not wrapped around one's body (i.e., hand, arm, torso), attached to load (not any sling), long enough for safe operation

  Yes

  No

  N/A

• Add media

  Media

WELDER or WELDER HELPER

• Does the employee perform welding duties as part of their regular duties

  Yes

  No

• Is the employee familiar with PPE requirements associated with welding duties

  Yes

  No

  N/A

• Can the employee demonstrate or describe proper hand tool selection and inspection associated with welding duties?

  Yes

  No

  N/A

• Are the welding machines on location grounded

  Yes

  No

  N/A

• Have all the oxygen and acetylene connection fittings been checked for leaks prior to use? (Spray bottle with soap and water)

  Yes

  No

  N/A

• Are all of the leads properly insulated with no bare wire exposure

  Yes

  No

  N/A

• Is the welding area well ventilated

  Yes

  No

  N/A

• Are compressed gas cylinders secure and stored in an upright position? Are the valves closed when not in use (Break Time)

  Yes

  No

  N/A

• Is the employee aware of when a fire watch must be assigned (Verify training card)

  Yes

  No

  N/A

• Add media

  Media

PERSONAL PROTECTIVE EQUIPMENT

• Is the employee familiar with Acadian Contractors Inc. PPE policies

  Yes

  No

  N/A

• Is the employee wearing long sleeves and are they rolled down?

  Yes

  No

  N/A

• Is the employee utilizing all other PPE required for the task being performed

  Yes

  No

  N/A

• Can the employee demonstrate proper inspection of PPE

  Yes

  No

  N/A

• Does the employee understand the limitations of PPE

  Yes

  No

  N/A

• Is all of the employee's PPE in good condition

  Yes

  No

  N/A

• Are machine guards in place

  Yes

  No

  N/A

• Is the employee familiar with Acadian Contractors' cellular device policy?

  Yes

  No

  N/A

• Add media

  Media

PAINT AND ABRASIVE BLASTING

• Does the employee perform painting and/ or also abrasive blasting duties as part of their regular position related responsibilities

  Yes

  No

  N/A

• Is hearing protection being utilized if the exposure is greater than 80dB and double hearing protection if the exposure is greater than 100dB

  Yes

  No

  N/A

• Has the employee inspected airlines and connections for wear and damage prior to use

  Yes

  No

  N/A

• Have all fittings and valves been checked for tightness and found to be in good operating condition

  Yes

  No

  N/A

• Is the employee using proper lifting devices and/or techniques while loading and handling abrasives

  Yes

  No

  N/A

• Is the employee wearing the proper PPE while mixing and handling hazardous chemicals such as paint and solvents lifting, i.e. goggles, face shield and correct gloves

  Yes

  No

  N/A

• Is the employee equipped with and also utilizing a NIOSH approved respirator when required? Is it properly maintained and stored?

  Yes

  No

  N/A

• Are safety labels protected for task affiliated damages? (Manufactures warning labels and equipment gauges protected from overspray or blasting damage)

  Yes

  No

  N/A

• Does the affiliated blasting machine equipment have in place a working dead man switch

  Yes

  No

  N/A

• If there is scaffolding equipment in use; has it been setup properly and inspected daily

  Yes

  No

  N/A

• Is the breathing air filtered to remove moisture, oil mists, and particulates

  Yes

  No

  N/A

• Is the air supply at least CGA "Grade D"

  Yes

  No

  N/A

• Add media

  Media

HOT WORK AND FIRE WATCH

• Does the employee perform hot work or fire watch duties as part of their regular position related responsibilities

  Yes

  No

• Can the employee describe when a hot work permit is required

  Yes

  No

  N/A

• Can the employee explain when a fire watch is required

  Yes

  No

  N/A

• Is the employee aware of how long a fire watch must remain on site following the completion of hot work

  Yes

  No

  N/A

• Can the employee explain what safety equipment is required when a hot-work permit is required, i.e. proper extinguisher, gas detector, evacuation plan, permit...

  Yes

  No

  N/A

• Does the employee understand the differences between types of fire extinguishers (Classes A, B, C, D & K)

  Yes

  No

  N/A

• Is the employee aware of specific fire blanket requirements

  Yes

  No

  N/A

• Add media

  Media

• Was a hot-work permit required for this site during this visit? If so was it in place prior to task commencement?

  Yes

  No

  N/A

BEHAVIOR BASED SAFETY PROCESS

• Is athe employee proficient with using the company's BBS process and are cards available on site

  Yes

  No

  N/A

• Is there evidence of employee participating in the BBS process

  Yes

  No

  N/A

• Does the employee understand how to properly complete a behavior based TAKE 5 CARD

  Yes

  No

  N/A

• Is feedback given after a BBS observation

  Yes

  No

  N/A

• Add media

  Media

• Is the employee familiar with the company's stop work authority policy

  Yes

  No

  N/A

• If so are they comfortable with utilizing the process

  Yes

  No

  N/A

JSEA

• Yes

  No

  N/A

• Was there a JSEA prepared for the task being performed upon arrival

  Yes

  No

  N/A

• Can the employee explain when a JSEA must be updated

  Yes

  No

  N/A

• Are all (SSE) short service employees identified on the JSEA along with their assigned mentor

  Yes

  No

  N/A

• Can the employee demonstrate proper completion of a JSEA

  Yes

  No

  N/A

• Add media

  Media

ACCIDENT/NEAR MISS REPORTING

• Is the employee familiar with reporting criteria and procedures

  Yes

  No

  N/A

• Can the the employee clearly define near miss

  Yes

  No

  N/A

• Can the employee clearly define a first aid

  Yes

  No

  N/A

• Add media

  Media

FUEL TRANSFER

• Can the employee describe and/or demonstrate proper fueling procedures

  Yes

  No

  N/A

• Is the employee aware that all spills must be reported immediately

  Yes

  No

  N/A

• Add media

  Media

SHORT SERVICE EMPLOYEES

• Is the employee able to describe how SSE's are identified (HI VIS ORANGE HARDHAT)

  Yes

  No

  N/A

• Are all SSE employees assigned a mentor who is documented on the JSEA

  Yes

  No

  N/A

• Verify the mentor knows that they are assigned to the SSE and that SSE's safety is their responsibility

  Yes

  No

  N/A

• Add media

  Media

FORK-LIFT/ INDUSTRIAL TRUCK/ GENERAL

• Does the employee operate the specified equipment as part of their duties

  Yes

  No

• Can the employee demonstrate proper inspection procedures

  Yes

  No

  N/A

• Is the employee able to demonstrate that they are able to raise a load in a controlled safe manner

  Yes

  No

  N/A

• Can employee demonstrate lowering a load in a controlled safe manner

  Yes

  No

  N/A

• Does the employee lock out the equipment when operations are complete

  Yes

  No

  N/A

• Ask the employee about traveling with a load and what is required of them as an operator if they are within 10FT of an obstacle. Are they aware of the policy?

  Yes

  No

  N/A

• Is the employee able to identify proper rigging and lifting equipment? If so can they also describe the required maintenance and inspection process?

  Yes

  No

  N/A

• If possible, have an experienced operator are supervisor familiar with proper equipment operations available during review.

• Add media

  Media

CRANE/ LIFTING OPERATIONS

• Does the employee operate a crane as part of their duties

  Yes

  No

• Ask to verify the crane operator card. Is the card current and appropriate for the crane being operated

  Yes

  No

  N/A

• Can the operator demonstrate a proper crane inspection (N/A if not a requirement for the observed task)

  Yes

  No

  N/A

• Can the operator demonstrate knowledge of crane load chart (N/A if not a requirement for the observed task)

  Yes

  No

  N/A

• Does operator appear to have proper and reasonable control of the machine while in operation

  Yes

  No

  N/A

• Give the operator some test hand signals, does he understand proper handsignals

  Yes

  No

  N/A

• Add media

  Media

DRIVER/ VEHICLE OPERATOR

• Is the employee assigned a company vehicle for transportation? If so, is the vehicle on site

  Yes

  No

  N/A

• Does the employee have available to verify a valid correct class drivers license

  Yes

  No

  N/A

• Was a pre-trip inspection performed before travel on the morning of this evaluation? Verify mileage-

  Yes

  No

  N/A

• Can the employee describe the company's journey management plan- (Must include the 360 walk-around or when a spotter in required in their inspection)

  Yes

  No

  N/A

• Is the vehicle equipped with an up-to-date inspected and properly mounted fire extinguisher

  Yes

  No

  N/A

• Can the employee explain the company's policy about using communication devices while operating a motor vehicle

  Yes

  No

  N/A

• Is the vehicles preventive maintenance current- i.e. fluid level accurate, tires in good condition, oil vs mileage accurate, lights work, etc.

  Yes

  No

  N/A

• Is the vehicle clean considering the work environment? Ask when was it washed last-

  Yes

  No

  N/A

• Add media

  Media

SUPERVISOR

• Is the evaluated employee a supervisor

  Yes

  No

  N/A

• Did the employee oversee the JSEA process and approve the written precautions documented?

  Yes

  No

  N/A

• Is the employee participating in task functions, oppose to delegating and overseeing- answer should be no, overseeing

  Yes

  No

  N/A

• Does the employee have available or immediate access to company forms such as incident occurrence, statement, property damage, early departure, etc. (Verify)

  Yes

  No

  N/A

• Can the employee describe their plan of action in the case of an emergency? (Heat Exhaustion) Prevention is the key-

  Yes

  No

  N/A

• Add media

  Media

SITE SPECIFIC

• Is the employee assigned to this site

  Yes

  No

• Position

  Welder, Helper, Roustabout, Rigger,

  Supervisor, Foreman

  Operator

  Painter, Blaster

• Can the employee describe emergency fire prevention practices associated with this site

  Yes

  No

  N/A

• Can the employee describe emergency evacuation procedures associated with this site

  Yes

  No

  N/A

• Can the employee describe emergency general alarm procedures

  Yes

  No

  N/A

• Is the employee able to identify the location of Safety Data Sheets and explain briefly what HAZARD COMMUNICATION is

  Yes

  No

  N/A

• Is employee familiar with machine guarding and hand held equipment inspections? If so, have the employee demonstrate an inspection-

  Yes

  No

  N/A

• Is the employee familiar with site specific rules and regulations, i.e. first-aid, eye-wash

  Yes

  No

  N/A

• Add media

  Media

CONCLUSION

• NOTES OR OBSERVATIONS:

• Is additional training required?

  Yes

  No

• Is the employee's current position knowledge capable of assuring the safety of personnel around them from danger? (If not contact their department manager immediately)

  Yes

  No

• CONTACT DEPARTMENT MANAGER IMMEDIATELY

• ENSURE TRAINING IS SCHEDULED ASAP

• Add media

  Media

ACKNOWLEDGEMENTS

• Evaluator Name

  Sign

• Employee Signature

  Sign