ADB Assessment rev.2

• Document No.

• Crew leader/foreman

• Personnel

• Conducted on

  Date
• Location
  Address

• Client / Site

• Weather conditions

• Prepared by

Personal protective Equipment

• Hard Hats in use by all personal?

  3

  2

  1

  n/a

• Eye protection in use by all personal?

  3

  2

  1

  n/a

• Reflective vest worn by all personal?

  3

  2

  1

  n/a

• Hearing protection in use when required?

  3

  2

  1

  n/a

• Proper foot wear?

  3

  2

  1

  n/a

Tools and Equipment.

• Tools and equipment in good condition?

  3

  2

  1

  n/a

• All equipment properly guarded?

  3

  2

  1

  n/a

• Electrical equipment connected properly, grounded and in good condition. GFCI automatic cut-off for woodworking tools?

  3

  2

  1

  n/a

• Machine guards/pinch points identified and protected?

  3

  2

  1

  n/a

• Rigging/ lifting equipment in good condition and inspected?

  3

  2

  1

  n/a

• Ladders in good condition; tied back; extended 3ft beyond landing?

  3

  2

  1

  n/a

Heavy Equipment

• Daily inspection complete?

  3

  2

  1

  n/a

• Fire extinguisher mounted and in good condition?

  3

  2

  1

  n/a

• Seatbelt worn during operation?

  3

  2

  1

  n/a

Worksite

• Warning devices (signs and cones) properly placed according to MUTCD?

  3

  2

  1

  n/a

• Safety cones in good condition and placed correctly?

  3

  2

  1

  n/a

• Traffic taper correctly positioned?

  3

  2

  1

  n/a

• Breaks set on truck/chock on unhitched trailer?

  3

  2

  1

  n/a

• Engine Idle? ( Truck or Equipment)

  3

  2

  1

  n/a

• Equipment properly secured on the truck/trailer?

  3

  2

  1

  n/a

General

• Safe access to work site?

  3

  2

  1

  n/a

• Good house keeping?

  3

  2

  1

  n/a

• Barricades/debris/warning signs in place around pot holes?

  3

  2

  1

  n/a

• Excavations / trenches properly protected spoil pile 2 feet away from excavation?

  3

  2

  1

  n/a

• Shoring properly installed/ tabulated data on site?

  3

  2

  1

  n/a

• First aid kit/ eye wash available?

  3

  2

  1

  n/a

• Utilities properly located/identified?

  3

  2

  1

  n/a

• Pre-task cards reviewed by work crew?

  3

  2

  1

  n/a

• Fire extinguisher: good condition; current inspection tag; within 50ft?

  3

  2

  1

  n/a

F. D. O. T.

• Lights/reflectors/bacons operational?

  3

  2

  1

  n/a

• Truck inspection completed?

  3

  2

  1

  n/a

• Truck cab neat/vehicle clean?

  3

  2

  1

  n/a

• Trailer properly mounted and free of debris?

  3

  2

  1

  n/a

• Tires within acceptable depth?

  3

  2

  1

  n/a

Behaviors

• Push, don't pull?

  Yes

  No

  N/A

• Turn, don't twist?

  Yes

  No

  N/A

• Squat, don't bend?

  Yes

  No

  N/A

• Load close to the body?

  Yes

  No

  N/A

• Was the crew open to coaching?

  Yes

  No

  N/A

• How was the crews attitude towards safety?

• List any other behaviors you saw on site.

  Safe

  At Risk

  N/A

• Signature

  Sign