Appendix M: Work Site Safety Inspection Form

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Superintendent's Name: Justin DeGan

Specific Area(s) Inspected: Kaiser Sustaining

Pre-Work

• Pre Task Plan communicated, understood and signed by each worker?

  Yes

  No

  N/A

• Pre Task Plan posted in conspicuous place at work site?

  Yes

  No

  N/A

• Workers physically ready for work?

  Yes

  No

  N/A

• MSDS Sheets obtained and available?

  Yes

  No

  N/A

• All required permits obtained?

  Yes

  No

  N/A

• Lockout/Tagout performed?

  Yes

  No

  N/A

• All training completed for work to be performed?

  Yes

  No

  N/A

Personal Protective Equipment

• Hardhat bills forward?

  Yes

  No

  N/A

• Face shields

  Yes

  No

  N/A

• Gloves

  Yes

  No

  N/A

• Safety glasses with side shields

  Yes

  No

  N/A

• Burning goggles

  Yes

  No

  N/A

• Hearing Protection

  Yes

  No

  N/A

• Leather Work Boots

  Yes

  No

  N/A

• Welding Hood & Gloves

  Yes

  No

  N/A

• Reflective Vest

  Yes

  No

  N/A

Fall Protection (100% Fall Protection Required at six feet or greater)

• Guardrail System Checked

  Yes

  No

  N/A

• Floor Openings Covered

  Yes

  No

  N/A

• Blue Fence Up

  Yes

  No

  N/A

• Harness and Lanyard Checked

  Yes

  No

  N/A

• Roof Openings Guarded

  Yes

  No

  N/A

• Netting Checked

  Yes

  No

  N/A

• Horizontal Lifeline Checked

  Yes

  No

  N/A

• Wall Openings Guarded

  Yes

  No

  N/A

Ladders & Scaffold

• Ladder Tied Off

  Yes

  No

  N/A

• Scaffold Inspected & Tagged

  Yes

  No

  N/A

• Ladder Access

  Yes

  No

  N/A

• Ladder Extended Three Feet

  Yes

  No

  N/A

• Sections Properly Pinned

  Yes

  No

  N/A

• Handrail In Place

  Yes

  No

  N/A

• Step Ladders In Open Position

  Yes

  No

  N/A

• Components Not Damaged

  Yes

  No

  N/A

• Planking Secured

  Yes

  No

  N/A

Housekeeping

• Material Stacked & Orderly

  Yes

  No

  N/A

• Cords & Hoses Off Floor

  Yes

  No

  N/A

• Trash Cans In Work Area

  Yes

  No

  N/A

• Access Maintained

  Yes

  No

  N/A

• Debris Removed

  Yes

  No

  N/A

Hoisting & Rigging Equipment

• Daily Crane Inspection

  Yes

  No

  N/A

• Qualified Rigger Named

  Yes

  No

  N/A

• Slings & Chokers Inspected

  Yes

  No

  N/A

• One-eye per Hook

  Yes

  No

  N/A

• Safety Latch on Hook Checked

  Yes

  No

  N/A

• Knowledge of Crane Signals

  Yes

  No

  N/A

• Sling/Chokers Stored

  Yes

  No

  N/A

• Cranes Flagged Off

  Yes

  No

  N/A

• Lift Zone Designated

  Yes

  No

  N/A

Mobile Equipment

• Seatbelts Used

  Yes

  No

  N/A

• Backup Alarms Working

  Yes

  No

  N/A

• Workers Trained

  Yes

  No

  N/A

• Spotters used when needed

  Yes

  No

  N/A

• Equipment Inspected

  Yes

  No

  N/A

Excavations

• Competent Person Named

  Yes

  No

  N/A

• Proper Access / Egress

  Yes

  No

  N/A

• Shores / Shield / Slope / Bench

  Yes

  No

  N/A

• Spoil Pile 2' From Edge

  Yes

  No

  N/A

• Excavation Checked Daily

  Yes

  No

  N/A

• Workers Trained

  Yes

  No

  N/A

Temporary Barricades

• Proper Tape Used (Red-Danger, Yellow-Caution)

  Yes

  No

  N/A

• All Sides Barricaded

  Yes

  No

  N/A

• Barricade Removed or Disposed of Properly

  Yes

  No

  N/A

• Temporary Walls in Good Condition & Maintained

  Yes

  No

  N/A

• HEPA filtration on and maintained

  Yes

  No

  N/A

• Negative pressure of -0.02 achieved

  Yes

  No

  N/A

Electrical

• Cords Check for Damage

  Yes

  No

  N/A

• Current Quarterly Inspection Color on Cords

  Yes

  No

  N/A

ILSM Measures

• Fire Extinguishers Inspected Monthly

  Yes

  No

  N/A

• Fire Extinguishers charged and pins installed

  Yes

  No

  N/A

• ILSM signage in place

  Yes

  No

  N/A

• Fire Strobes visible and functional

  Yes

  No

  N/A