AEGION E&M FIELD SITE INSPECTION FORM

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• General Data:

• Office

• Supervisor

• Work description

• Subcontractors Onsite

• Subs name

General Area

• JSA complete and reviewed with workers

  Yes

  No

  N/A

• Workers instructed on site hazards and controls

  Yes

  No

  N/A

• Toolbox meeting conducted

  Yes

  No

  N/A

• Observations being conducted

  Yes

  No

  N/A

• Workers properly trained

  Yes

  No

  N/A

• Workers know Emergency Action Plan

  Yes

  No

  N/A

• Sufficient supply of PPE

  Yes

  No

  N/A

• SDS available or accessible

  Yes

  No

  N/A

• First Aid on site, workers know location

  Yes

  No

  N/A

• Fire Extinguisher Onsite

  Yes

  No

  N/A

• Workers have Health Bridge Number

  Yes

  No

  N/A

• Underground utilities identified by one call

  Yes

  No

  N/A

Electrical

• All extension cords inspected and tagged

  Yes

  No

  N/A

• Generators grounded

  Yes

  No

  N/A

• GFCI in use

  Yes

  No

  N/A

• LOTO equipment available

  Yes

  No

  N/A

Equipment

• Equipment inspections completed and documented

  Yes

  No

  N/A

• All guards installed

  Yes

  No

  N/A

• Derricks/booms lowered while moving equipment

  Yes

  No

  N/A

• Chains, tie downs, ropes inspected

  Yes

  No

  N/A

• Have PM's been completed on all equipment

  Yes

  No

  N/A

• Equipment is sufficient distance (min 20') from overhead lines

  Yes

  No

  N/A

Personal Protective Equipment

• Are all employees wearing required amount

  Yes

  No

  N/A

• Is it being worn correctly

  Yes

  No

  N/A

• Is it clean and in good order

  Yes

  No

  N/A

• Is it appropriate for the hazards

  Yes

  No

  N/A

• Working near navigation waterways

  Yes

  No

  N/A

• Respirators required

  Yes

  No

  N/A

Hand Safety

• Are employees aware of hazards

  Yes

  No

  N/A

• Have employees been trained in hand safety

  Yes

  No

  N/A

• The appropriate gloves available

  Yes

  No

  N/A

• Pinch points identified on JSA

  Yes

  No

  N/A

• During cutting activities are Kevlar gloves on non cutting hand

  Yes

  No

  N/A

Fall protection

• Equipment inspections completed

  Yes

  No

  N/A

• Fall plan required

  Yes

  No

  N/A

• Rescue plan verified

  Yes

  No

  N/A

• Is equipment appropriate

  Yes

  No

  N/A

Excavation

• Competent person on site

  Yes

  No

  N/A

• Excavation inspection completed

  Yes

  No

  N/A

• Excavation guarded appropriately

  Yes

  No

  N/A

• Adequate means of entry and egress

  Yes

  No

  N/A

• Excavation site secured

  Yes

  No

  N/A

Confined Space Entry

• Permit required?

  Yes

  No

  N/A

• Permit in place and completed?

  Yes

  No

  N/A

• Gas monitor available and calibrated

  Yes

  No

  N/A

• Rescue plan in place

  Yes

  No

  N/A

Vehicle Safety

• DOT logbooks up to date

  Yes

  No

  N/A

• Pre trip inspection completed

  Yes

  No

  N/A

• Vehicles clean and orderly

  Yes

  No

  N/A

Other

• Anything removed from service

  Yes

  No

  N/A

• Items requiring repair

  Yes

  No

  N/A

• Safety concerns

  Yes

  No

  N/A

• Comments

  Yes

  No

  N/A

Sign Off

• On site representative

  Sign

• Auditor's signature

  Sign