ADB Subcontractor Assessment

• Document No.

• Company Name

• Supervisor/Foreman

• Conducted on

  Date
• Location
  Address

• Client / Site

• Weather conditions

• Prepared by

General

• Pre-task cards reviewed by work crew? (At Risk = AUTO FAIL)

  Safe

  At Risk

  N/A

• Safe access to work site?

  Safe

  At Risk

  N/A

• Good house keeping?

  Safe

  At Risk

  N/A

• Fire extinguisher: good condition; current inspection tag?

  Safe

  At Risk

  N/A

• Utilities properly located/identified?

  Safe

  At Risk

  N/A

• Fencing and/or flagging tape in place around pot holes?

  Safe

  At Risk

  N/A

Personal protective Equipment

• Hard Hats in use by all personal? (At Risk = AUTO FAIL)

  Safe

  At Risk

  N/A

• Eye protection in use by all personal?

  Safe

  At Risk

  N/A

• Reflective vest worn by all personal?

  Safe

  At Risk

  N/A

• Hearing protection in use when required?

  Safe

  At Risk

  N/A

Tools and Equipment.

• Tools and equipment in good condition?

  Safe

  At Risk

  N/A

• Strike Alert Operational and pre operational check completed?

  Safe

  At Risk

  N/A

• Machine guards/pinch points identified and protected?

  Safe

  At Risk

  N/A

• Are extension cords in good condition? (no frays, ground prong in place, no holes in outer jacketing)

  Safe

  At Risk

  N/A

• Rigging/ lifting equipment in good condition and inspected?

  Safe

  At Risk

  N/A

• Ladders in good condition? (no cracks, broken parts)

  Safe

  At Risk

  N/A

Heavy Equipment

• Fire extinguisher mounted and in good condition?

  Safe

  At Risk

  N/A

• Seatbelt worn during operation?

  Safe

  At Risk

  N/A

Worksite

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

  Safe

  At Risk

  N/A

• Safety cones in good condition? (Double reflective tape for roadway use, faded, torn)

  Safe

  At Risk

  N/A

• Traffic taper correctly positioned?

  Safe

  At Risk

  N/A

• Sidewalks closed properly to prevent injury to the public?

  Safe

  At Risk

  N/A

• Breaks set on truck/chock on unhitched trailer?

  Safe

  At Risk

  N/A

• Flagger performing duties properly and placed in a safe location?

  Yes

  No

  N/A

• First aid kit/ eye wash available?

  Safe

  At Risk

  N/A

Trenching and Excavations

• Excavations / trenches properly protected? (At Risk = AUTO FAIL)

  Safe

  At Risk

  N/A

• Shoring properly installed/ tabulated data on site? (At Risk = AUTO FAIL)

  Safe

  At Risk

  N/A

• Spoil piles/tools 2 feet or further away from the trench? (At Risk = AUTO FAIL)

  Safe

  At Risk

  N/A

• No standing water in the trench? (At Risk = AUTO FAIL)

  Safe

  At Risk

  N/A

• Are there proper means of egress? (4 feet or more a ladder must be used) (At Risk = AUTO FAIL)

  Safe

  At Risk

  N/A

Fall Protection

• Fall Protection Equipment inspected?

  Safe

  At Risk

  N/A

• Fall Protection equipment in good working order?

  Safe

  At Risk

  N/A

• 100% tie off practices in use?

  Safe

  At Risk

  N/A

Personnel Lifting/Aerial Booms

• 100% Fall Protection in use?

  Safe

  At Risk

  N/A

• Lift device and alarms operational?

  Safe

  At Risk

  N/A

• Any damage to the boom and/or lifting device during the Assessment? (If At Risk operations should stop immediately until inspected by competent person and/or maintenance)

  Safe

  At Risk

  N/A

Behaviors

• Did the crew discuss a Good Catch/Near Miss with you during the Assessment?

  Yes

  No

  N/A

• Enter Good Catch/Near Miss discussed, or enter coaching performed if no Good Catch/Near Miss was discussed.