Title Page

  • Document No.

  • Crew leader/foreman

  • Personnel

  • Conducted on

  • Location
  • Client / Site

  • Weather conditions

  • Prepared by

Personal protective Equipment

  • Hard Hats in use by all personal?

  • Eye protection in use by all personal?

  • Reflective vest worn by all personal?

  • Hearing protection in use when required?

  • Proper foot wear?

Tools and Equipment.

  • Tools and equipment in good condition?

  • All equipment properly guarded?

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

  • Machine guards/pinch points identified and protected?

  • Rigging/ lifting equipment in good condition and inspected?

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

Heavy Equipment

  • Daily inspection complete?

  • Fire extinguisher mounted and in good condition?

  • Seatbelt worn during operation?

Worksite

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

  • Safety cones in good condition and placed correctly?

  • Traffic taper correctly positioned?

  • Breaks set on truck/chock on unhitched trailer?

  • Engine Idle? ( Truck or Equipment)

  • Equipment properly secured on the truck/trailer?

General

  • Safe access to work site?

  • Good house keeping?

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

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

  • Shoring properly installed/ tabulated data on site?

  • First aid kit/ eye wash available?

  • Utilities properly located/identified?

  • Pre-task cards reviewed by work crew?

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

F. D. O. T.

  • Lights/reflectors/bacons operational?

  • Truck inspection completed?

  • Truck cab neat/vehicle clean?

  • Trailer properly mounted and free of debris?

  • Tires within acceptable depth?

Behaviors

  • Push, don't pull?

  • Turn, don't twist?

  • Squat, don't bend?

  • Load close to the body?

  • Was the crew open to coaching?

  • How was the crews attitude towards safety?

  • List any other behaviors you saw on site.

  • Signature

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