Action Notice

• Employee name

• Client / Site

• Conducted on

  Date

• Prepared by

PPE

• Use of safety glasses

  Proper use

  Not being used

• Use of hard hat

  Proper use

  Not being used

• Other

Ladders

• Use of Extension ladder

  Not tied off

  Not 3 feet above

  Proper use

• Use of A frame ladder

  Leaning A frame

  Standing on top of A frame

  Proper use of ladder

• Other

SWPPS

• Compressor containment

  Yes

  No

  N/A

• Generator containment

  Yes

  No

  N/A

• Site conditions

  In compliance

  Not in compliance

• Other

Tools

• Nail guns

  Safe

  At Risk

  N/A

• Power tools

  Safe

  At Risk

  N/A

• Hilti

  Safe

  At Risk

  N/A

• Skill saw

  Safe

  At Risk

  N/A

• Other

House keeping

• Trash cleaned up

  Yes

  No

  N/A

• Lumber cleaned up

  Yes

  No

  N/A

• Hardware cleaned up

  Yes

  No

  N/A

• Nails bent

  Yes

  No

  N/A

• Clear path

  Yes

  No

  N/A

• Other

Fall protection

Floor level

• Guard rails installed per plan

  Yes

  No

  N/A

• Leading edge lines

  Yes

  No

  N/A

• Equipment used per plan

  Yes

  No

  N/A

• 2nd floor windows guarded

  Yes

  No

  N/A

• Other

Roof level

• Bracket scaffold installed per plan

  Yes

  No

  N/A

• Harness used per plan

  Yes

  No

  N/A

• Net installed per plan

  Yes

  No

  N/A

• Other

• Other comments

• Immediate corrective action implemented

• Follow up steps required

• Follow up required?

• Employee signature

  Sign

• Notice given by

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