ATLANTA STADIUM PARTNERS

• Add location
  Address

• Job-site Name and Number

• Conducted on

  Date

• Prepared by:

• Superintendent Onsite

• Any Safety Citations pertaining to this subject will be in the Citation Section

Housekeeping

• Adequate trash containers provided?

  Safe

  At Risk

  N/A

• Rank Housekeeping:

  Safe

  At Risk

  N/A

• Location and companies involved:

• Identify the issue:

• Is a corrective action taking place?

  Yes

  No

  N/A

• Explain who is conducting the corrective action and what all has to be taken place to correct the issue:

• Mandatory Posting Requirements:

Mandatory Postings

• Are mandatory posting requirements provided and visible at the job site?

  Safe

  At Risk

  N/A

• Pre-Task Plans

PTP

• Are Daily Job Hazard Analysis (Pre-Task Plan) being completed?

  Safe

  At Risk

  N/A

• STOP THE WORK ACTIVITY UNTIL ONE IS CONDUCTED

• Company:

• Time

  Date

• What area if not conducted?

• Bring the Foreman to the area prior to work activities continuing:

• Supervisor must sign after Pre-Task is completed here:

  Sign

• Is a Safety Citation required?

  Yes

  No

  N/A
Citation

• Name of whom is receiving the Citation:

• Supervisor is to sign acknowledging the citation

  Sign

• Late PTP being submitted:

Late PTP

• Company Name:

• How late (Number of days- Must be submitted before 8:00 a.m. The following work day)

• How many are submitted late?

• Enter number of days past due:

• Call Supervisor and have them to come and acknowledge late paperwork being submitted

• Supervisor Signature

  Sign

• Late Documentation:

Late Documentation

• Company Name:

• Name of Document being submitted late.

• Call Supervisor and have them to come and acknowledge late paperwork being submitted

• Supervisor Signature

  Sign

• Are emergency phone numbers posted?

  Safe

  At Risk

  N/A

• OSHA 300 and 300 A

OSHA 300 Log

• Is the OSHA 300 A log posted and visible on the months of February, March, and April?

  Safe

  At Risk

  N/A

• Are occupational injuries or illnesses, except minor injuries requiring only first aid, recorded as required on the OSHA 300 log?

  Safe

  At Risk

  N/A
First Aid

• Is a first aid log up to date with minor injuries?

  Safe

  At Risk

  N/A

• Is a first aid kit stocked, and easily accessible to employees?

  Safe

  At Risk

  N/A
Eye Wash

• Is there an eye-wash station or sink available for quick drenching or flushing of the the eyes and body?

  Safe

  At Risk

  N/A

• Is eye wash readily available to supplement the station?

  Safe

  At Risk

  N/A

• Any protruding/impalement objects exposed?

  Safe

  At Risk

  N/A
Potable Water

• Are potable drinking containers provided for employees on the job site?

  Safe

  At Risk

  N/A

• Name methods personnel are receiving potable Water:

• Access & Egress

Access &a Egress

• Are walkways kept clear and identified if in need?

  Safe

  At Risk

  N/A

• Are changes of direction or elevations readily identifiable?

  Safe

  At Risk

  N/A
Barricades

• Are proper barricades being used per the task ( Caution/Danger)

  Safe

  At Risk

  N/A

• Location

• Company

• Select date

  Date

• Are corrections being made?

  Yes

  No

  N/A

• Name of responsible Personnel and Company:

• Is proper contact information placed on the barricade?

  Safe

  At Risk

  N/A

• Are corrections being made?

  Safe

  At Risk

  N/A

• Name of responsible party member with Company:

• When lasers are in use has all proper signage and warnings been displayed?

  Safe

  At Risk

  N/A

Additional information

Corrective Actions

• We're there any other hazards or safety issues that need Corrective Action?

  Yes

  No

  N/A

• Identify the hazard and document the Corrective Action:

• Add media

  Media

• Responsible Party(s):

• Is the Corrective Action being corrected?

  Yes

  No

  N/A

• Who is correcting this issue:

• Document what is to be taken place by whom is correcting the issue

• Assign here the deadline on when it will be corrected

  Date

• Supervisor is to sign acknowledging all what is above on this subject

  Sign

• Ensure a follow up on this issue

• STOP the work activity until a Corrective Action can be taken.

• Have the Supervisor come to the work area and discuss the issue

• Supervisor is to sign acknowledging this issue and that the work activity cannot continue until a Corrective Action takes place.

  Sign

• Assign a follow up on this issue

• Safety Citations for this Subject may be either found here or under the Citation Section

Eye Protection

• Are all employee's wearing safety glasses 100% of the time on the job-site?

  Safe

  At Risk

  N/A

• How many are found to be hazardous.

• Has the employee(s) been verbally warned in the past?

  Yes

  No

  N/A

• Has the employee received a written warning?

  Yes

  No

  N/A

• Give the employee an official written warning, take a picture of the warning, and have the Supervisor sign below.

• Supervisor signing and acknowledging the written warning.

  Sign

• Has the employee received a 24 hour suspension?

  Yes

  No

  N/A

• Issue official 24 hour suspension with the Supervisor being aware. Take a picture of the citation.

• Supervisor is to sign acknowledging the citation.

  Sign

• The employee is now in question of being removed off the project. This is to be addressed with their Supervision on further disciplinary action or immediate termination.

• Document discussion with Supervisor here.

• Supervisor is to sign acknowledging the discussion.

  Sign

• Give him an official verbal warning and Document the name below.

• Employee Name-Number-and Employer

Gloves

• Are all employee's wearing suitable gloves pertaining to their task?

  Safe

  At Risk

  N/A

• How many are found to be hazardous.

• Has the employee(s) been verbally warned in the past?

  Yes

  No

  N/A

• Has the employee received a written warning?

  Yes

  No

  N/A

• Supervisor signing and acknowledging the written warning.

  Sign

• Has the employee received a 24 hour suspension?

  Yes

  No

  N/A

• Issue official 24 hour suspension with the Supervisor being aware. Take a picture of the citation.

• Supervisor is to sign acknowledging the citation.

  Sign

• The employee is now in question of being removed off the project. This is to be addressed with their Supervision on further disciplinary action or immediate termination.

• Document discussion with Supervisor here.

• Supervisor is to sign acknowledging the discussion.

  Sign

• Employee Name-Number-and Employer

• Give the employee an official written warning, take a picture of the warning, and have the Supervisor sign below.

• Supervisor is to sign acknowledging this citation.

  Sign
Hard Hats

• Are employee's wearing hard-hats at all times on the job-site?

  Safe

  At Risk

  N/A

• How many are found to be hazardous.

• Has the employee(s) been verbally warned in the past?

  Yes

  No

  N/A

• Has the employee received a written warning?

  Yes

  No

  N/A

• Give the employee an official written warning, take a picture of the warning, and have the Supervisor sign below.

• Supervisor signing and acknowledging the written warning.

  Sign

• Has the employee received a 24 hour suspension?

  Yes

  No

  N/A

• Issue official 24 hour suspension with the Supervisor being aware. Take a picture of the citation.

• Supervisor is to sign acknowledging the citation.

  Sign

• The employee is now in question of being removed off the project. This is to be addressed with their Supervision on further disciplinary action or immediate termination.

• Document discussion with Supervisor here.

• Supervisor is to sign acknowledging the discussion.

  Sign

• Give him an official verbal warning and Document the name below.

• Employee Name-Number-and Employer

• Are any of the employee's hard-hats visibly damaged or in need of replacement?

  Safe

  At Risk

  N/A

• Remove the hard hat and have their employer issue them a new one. Take a picture of the hard hat.

• N-95 Dust Mask/ respirators being used with a voluntary use of a disposable respirator filed and signed?

  Safe

  At Risk

  N/A

• Are control measures put in place such as fans, water, and vacuums to contain/control/reduce dust particle exposure to employee's and the environment?

  Safe

  At Risk

  N/A
Safety Vest

• Reflective Vests or high visibility shirts worn on-site

  Safe

  At Risk

  N/A
Hearing Protection

• Does this area have a higher decibel level above 85?

  Safe

  At Risk

  N/A

• Record the decibel level.

• Document the corrective action.

• Are Hard Sole Work Boots being worn for the project?

  Safe

  At Risk

  N/A

• Face shields worn on all needed tasks such as welding,cutting, or a possible splash of harsh chemicals?

  Safe

  At Risk

  N/A

• Have both the Supervisor and the employees been trained on PPE procedures, i.e., what PPE necessary for job task, when workers need it, and how to properly wear and adjust it?

  Safe

  At Risk

  N/A

• Are appropriate procedures in place to dispose of or decontaminate PPE contaminated with, or reasonably anticipated to be contaminated with, blood or other potentially infections materials?

  Safe

  At Risk

  N/A

Additional information

Corrective Actions

• We're there any other hazards or safety issues that need Corrective Action?

  Yes

  No

  N/A

• Identify the hazard and document the Corrective Action:

• Add media

  Media

• Responsible Party(s):

• Is the Corrective Action being corrected?

  Yes

  No

  N/A

• Who is correcting this issue:

• Document what is to be taken place by whom is correcting the issue

• Assign here the deadline on when it will be corrected

  Date

• Supervisor is to sign acknowledging all what is above on this subject

  Sign

• Ensure a follow up on this issue

• STOP the work activity until a Corrective Action can be taken.

• Have the Supervisor come to the work area and discuss the issue

• Supervisor is to sign acknowledging this issue and that the work activity cannot continue until a Corrective Action takes place.

  Sign

• Assign a follow up on this issue

• Any Safety Citations pertaining to this subject will be in the Citation Section

• Safety cans are used to store gasoline or diesel? (Plastic cans are prohibited on the job-site).

  Safe

  At Risk

  N/A

• Are cans properly labeled with what it contains? (Glue, Primer, Mixed GAS, etc.)

  Safe

  At Risk

  N/A

• Fire Extinguisher

Fire Extinguisher

• Are fire extinguishers available for all areas? (Fuel containers on-site, fuel storages, all equipment on-site, etc.)

  Safe

  At Risk

  N/A

• Fire Extinguishers should be found for every 3,000 square feet/ 100 feet of lateral travel.

• Are all the requirements met on labeling and protecting storage areas such as "no smoking signs" and a berm around the tanks?

  Safe

  At Risk

  N/A

• Propane is not stored inside?

  Safe

  At Risk

  N/A

• Hose lines are not exposed to damage?

  Safe

  At Risk

  N/A

• Propane storage areas have "No Smoking" signs posted and are barricaded by high visible fencing?

  Safe

  At Risk

  N/A

Additional information

Corrective Actions

• We're there any other hazards or safety issues that need Corrective Action?

  Yes

  No

  N/A

• Identify the hazard and document the Corrective Action:

• Add media

  Media

• Responsible Party(s):

• Is the Corrective Action being corrected?

  Yes

  No

  N/A

• Who is correcting this issue:

• Document what is to be taken place by whom is correcting the issue

• Assign here the deadline on when it will be corrected

  Date

• Supervisor is to sign acknowledging all what is above on this subject

  Sign

• Ensure a follow up on this issue

• STOP the work activity until a Corrective Action can be taken.

• Have the Supervisor come to the work area and discuss the issue

• Supervisor is to sign acknowledging this issue and that the work activity cannot continue until a Corrective Action takes place.

  Sign

• Assign a follow up on this issue

• Any Safety Citations pertaining to this subject will be in the Citation Section

Hot Work

Hot Work

• Hot Work area being conducted properly?

  Safe

  At Risk

  N/A

• Check all that are necessary to perform the task:

  Select Protective Welding Screen Fire Retardant Clothing Fire Extinguisher Welding Hood Face Shield Fire Blankets Fire Watch Flashback Arrestors Signature Prior to ACTIVITY Proceeding Heat Sources monitored in a 35 feet radius Area swept around

  • Protective Welding Screen
  • Fire Retardant Clothing
  • Fire Extinguisher
  • Welding Hood
  • Face Shield
  • Fire Blankets
  • Fire Watch
  • Flashback Arrestors
  • Signature Prior to ACTIVITY Proceeding
  • Heat Sources monitored in a 35 feet radius
  • Area swept around

• Check all that are being implemented for this task:

  Select Protective Welding Screen Fire Retardant Clothing Fire Extinguisher Welding Hood Face Shield Fire Blankets Fire Watch Flashback Arrestors Signature Prior to ACTIVITY Proceeding Heat Sources monitored in a 35 feet radius Area swept around

  • Protective Welding Screen
  • Fire Retardant Clothing
  • Fire Extinguisher
  • Welding Hood
  • Face Shield
  • Fire Blankets
  • Fire Watch
  • Flashback Arrestors
  • Signature Prior to ACTIVITY Proceeding
  • Heat Sources monitored in a 35 feet radius
  • Area swept around

• Are all objects subject to being caught on fire by the heat source away from the designated area?

  Yes

  No

  N/A

• A 20 lb. fire Extinguisher must be available for the Hot Work Activities.

• All objects subject to being caught on fire by the heat source is to be monitored in a 35 feet radius

• If arc welding activities are being performed, screening shall be implemented to shield arc.

• Are gauges and hoses free of defects?

  Safe

  At Risk

  N/A

• Are welding leads for arc welding not damaged or repaired 10 feet from the end of the lead.

  Safe

  At Risk

  N/A

Storage

• Are containers (Oxygen, Acetylene, etc.) labeled?

  Safe

  At Risk

  N/A

• Are they damaged in any way that warrants a removal from service tag?

  Safe

  At Risk

  N/A

• When being stored, Oxygen cylinders are separated from combustible cylinders and materials by 25ft.

  Safe

  At Risk

  N/A

Compressors

Compressors

• Are compressed gas cylinders free from obvious signs of defects, deep rusting, or leakage?

  Safe

  At Risk

  N/A

• If applicable are air compressors equipped with pressure relief valves and pressure gauges?

  Safe

  At Risk

  N/A

• Are employee's strictly prohibited from directing compressed air towards a person and if used for cleaning purposes trained to reduce the pressure to less than 10 pounds per square inch?

  Safe

  At Risk

  N/A
Whip Check

• Are safety chains or other suitable locking devices used at couplings of high-pressure hose lines where a connection failure would create a hazard?

  Safe

  At Risk

  N/A

Fire Watch

• Fire Watch Issue

Fire Watch issue

• Was the Fire Watch for the Hot Work present for the required time? (Duration plus 30 minutes)

  Safe

  At Risk

  N/A

• Is a 35 foot radius being monitored from the Fire Watch surrounding the Hot Work being conducted?

  Safe

  At Risk

  N/A

• Was a Monitor present one hour after Hot Work has been completed?

  Safe

  At Risk

  N/A

Additional information

Corrective Actions

• We're there any other hazards or safety issues that need Corrective Action?

  Yes

  No

  N/A

• Identify the hazard and document the Corrective Action:

• Add media

  Media

• Responsible Party(s):

• Is the Corrective Action being corrected?

  Yes

  No

  N/A

• Who is correcting this issue:

• Document what is to be taken place by whom is correcting the issue

• Assign here the deadline on when it will be corrected

  Date

• Supervisor is to sign acknowledging all what is above on this subject

  Sign

• Ensure a follow up on this issue

• STOP the work activity until a Corrective Action can be taken.

• Have the Supervisor come to the work area and discuss the issue

• Supervisor is to sign acknowledging this issue and that the work activity cannot continue until a Corrective Action takes place.

  Sign

• Assign a follow up on this issue

• Any Safety Citations pertaining to this subject will be in the Citation Section

Electrical Cord size

• Are the Cords found to be 12 gage at a minimum

  Safe

  At Risk

  N/A

• Remove cord from usage and discuss with the crew on not using a cord any smaller in gage for this project.

Electrical Cord Quality

• Has the assured grounding been completed for the month?

  Yes

  No

  N/A

• Company Name

• Select date

  Date

• Location

• Corrective Action taken

• Are 3-wire construction grade cords being used that are free of damage or defects?

  Safe

  At Risk

  N/A

• Company Name

• Select date

  Date

• Location

• Corrective Action taken

• Take photo of corrective action.

  Media
Suspended or Protected Cords:

• Are cords being suspended or protected?

  Safe

  At Risk

  N/A

• If overhead power lines exist, have measures been taken to address the hazard.

  Safe

  At Risk

  N/A

• Are Ground Fault Circuit Interruptors being utilized for all power tools and equipment?

  Safe

  At Risk

  N/A

• Panel box is provided with a cover. No knockouts or blanks are missing from panel.

  Safe

  At Risk

  N/A

Lock Out / Tag Out

• Did you observe or been informed of a Lock-out Tag-out procedure occurring today?

  Yes

  No

  N/A

• List Authorized Employees doing the task

• Do authorized employees know the location of the written procedure?

  Yes

  No

  N/A

• Have affected employees been notified when the procedure is being used?

  Yes

  No

  N/A

• Did each authorized employee lock out all energy sources?

  Yes

  No

  N/A

• Stop the activity immediately until the corrective action has taken place.

• Call the Supervisor to come to the area

• Name of company(s) involved

• Select date

  Date

• Document the Discussion made with the Supervisor here

• Supervisor is to sign acknowledging the conversation

  Sign

• Does this procedure involve group lockout/tag out?

  Yes

  No

  N/A

• Stop the activity immediately until the corrective action has taken place.

• Call the Supervisor to come to the area

• Name of company(s) involved

• Select date

  Date

• Document the Discussion made with the Supervisor here

• Supervisor is to sign acknowledging the conversation

  Sign

• Have all employees been trained in the procedure being conducted?

  Safe

  At Risk

  N/A

• Name who has not received training and from what company.

• Call the Supervisor and have the untrained personnel removed from the activity

• Did the authorized employees verify that the equipment was de-energized?

  Yes

  No

  N/A

• Did authorized employees follow the lockout/tag out procedure?

  Yes

  No

  N/A

• Did the foreman review with all authorized and employees their responsibilities under the procedure? Note: A review can be accomplished by meeting with employees with the Pre-task

  Yes

  No

  N/A

• Does the lockout/tag out procedure adequately protect employees?

  Yes

  No

  N/A

• List and describe the deficiencies requiring corrective action.

• Add all names involved

• Names and signatures

Personnel

• Attendee signature

  Sign

Energized Electrical Equipment

• Did you witness exposed equipment being worked on while energized?

  Yes

  No

  N/A

• Was a Energized Electrical Work Permit conducted for this task?

  Safe

  At Risk

  N/A

• If the equipment is energized and a work permit has not been conducted, then work is to be stopped immediately and questioned on why the permit was not done. If not sufficient then this is a major violation and suspension is required.

• Show the Permit if Provided.

  Media

• Provide the location of the area the work is being conducted. Also provide the description of the circuit/equipment being worked on along with what work is being conducted.

• Gather information on justification of why the circuit/equipment cannot be de-energized or the work deferred until the next scheduled outage.

• Was a Pre-Task Plan conducted for this task?

  Safe

  At Risk

  N/A

• STOP THE ACTIVITY IMMEDIATELY

• Remove personnel from the area

• Call Supervision to the area

• Document conversation with the Supervisor

• Supervisor sign to acknowledge the conversation

  Sign

• Is the area barricaded keeping unauthorized personnel away from the area with proper signage?

  Yes

  No

  N/A

Additional information

Corrective Actions

• We're there any other hazards or safety issues that need Corrective Action?

  Yes

  No

  N/A

• Identify the hazard and document the Corrective Action:

• Add media

  Media

• Responsible Party(s):

• Is the Corrective Action being corrected?

  Yes

  No

  N/A

• Who is correcting this issue:

• Document what is to be taken place by whom is correcting the issue

• Assign here the deadline on when it will be corrected

  Date

• Supervisor is to sign acknowledging all what is above on this subject

  Sign

• Ensure a follow up on this issue

• STOP the work activity until a Corrective Action can be taken.

• Have the Supervisor come to the work area and discuss the issue

• Supervisor is to sign acknowledging this issue and that the work activity cannot continue until a Corrective Action takes place.

  Sign

• Assign a follow up on this issue

• Any Safety Citations pertaining to this subject will be in the Citation Section

• Scaffolding

Scaffolding Ins

• Did you observe a scaffolding operation or inspect a scaffold?

  Yes

  No

  N/A

• Does a competent person exist?

  Yes

  No

  N/A

• Name of Competent Person

• Safe access is provided at all working levels.

  Safe

  At Risk

  N/A

• Guardrails are provided on working levels 10ft or more in height.

  Safe

  At Risk

  N/A

• Bases are provided on scaffold frame legs and mudsill (2 X 10 minimum)

  Safe

  At Risk

  N/A

• Working platforms are fully planked.

  Safe

  At Risk

  N/A

• Scaffolds are anchored properly?

  Safe

  At Risk

  N/A

• Guardrails are maintained at loading area.

  Safe

  At Risk

  N/A

• Is the scaffold being inspected prior to use?

  Safe

  At Risk

  N/A

• Components free of damage or defects

  Safe

  At Risk

  N/A

• Scaffolds secure from any danger (Electrical, foundation issues, etc.)?

  Safe

  At Risk

  N/A

Additional information

Corrective Actions

• We're there any other hazards or safety issues that need Corrective Action?

  Yes

  No

  N/A

• Identify the hazard and document the Corrective Action:

• Add media

  Media

• Responsible Party(s):

• Is the Corrective Action being corrected?

  Yes

  No

  N/A

• Who is correcting this issue:

• Document what is to be taken place by whom is correcting the issue

• Assign here the deadline on when it will be corrected

  Date

• Supervisor is to sign acknowledging all what is above on this subject

  Sign

• Ensure a follow up on this issue

• STOP the work activity until a Corrective Action can be taken.

• Have the Supervisor come to the work area and discuss the issue

• Supervisor is to sign acknowledging this issue and that the work activity cannot continue until a Corrective Action takes place.

  Sign

• Assign a follow up on this issue

• Any Safety Citations pertaining to this subject will be in the Citation Section

Guardrails

Guardrails

• Any observation of guardrails?

  Yes

  No

  N/A

• Guardrails provided and structurally sound.

  Safe

  At Risk

  N/A

• Location

• Select date

  Date

• Are guard rails set at the appropriate height in the working area being the Top rail ( 42 inches high + or - 3 inches)?

  Safe

  At Risk

  N/A

• Are guard rails set at the appropriate height in the work area being the mid-rail ( 21 inches + or - 3 inches)?

  Safe

  At Risk

  N/A

• Are the guard rails set at the appropriate heights in the working area being a Toe-board (3 1/2 inches tall supporting 50 pounds)?

  Safe

  At Risk

  N/A

• If guardrails are removed, is there a barricade established at least 15 feet away?

  Safe

  At Risk

  N/A

• Corrective Action conducted?

  Yes

  No

  N/A

Holes

• Holes

Hole

• Any observation of a hole?

  Yes

  No

  N/A

• Location

• Select date

  Date

• Floor holes are covered, secured and labeled "HOLE" or "COVER"

  Safe

  At Risk

  N/A

• Are floor hole covers able to support twice the intended load?

  Safe

  At Risk

  N/A

• Wall openings temporarily covered or guard railed?

  Safe

  At Risk

  N/A

• Are all floor hole covers placed correctly and serving their purpose protecting and covering the hole?

  Safe

  At Risk

  N/A

• Corrective Action needed?

  Yes

  No

  N/A

Personal Fall Arrest Systems

Fall Protection

• Rank Fall Protection/Restraint/Arrest Practices being implemented

  Safe

  At Risk

  N/A

• Select date

  Date

• Location

• Company Name

• Employee name in violation

• Has the employee been in violation in the past on a fall protection issue?

  Yes

  No

  N/A

• Supervisor is to be called to the area

• Discussion is to be made on violations done in the past with the Supervisor

• Due to Fall Protection violation being done in the past it is mandatory the employee be removed from the project.

• Image of the Citation

  Media

• Document discussion with Supervisor

• Signature with Supervisor acknowledging the citation, violation, and corrective action.

  Sign

• A mandatory 3 day suspension is to be issued to the violator

• Take a picture of the Citation

  Media

• Call the Supervisor to the area

Corrective Actions

• We're there any other hazards or safety issues in need of Corrective Action?

  Yes

  No

  N/A

• Identify the hazard and document the Corrective Action:

• If hazards or the likelihood of hazards are found, are Supervisors and Foremen selecting appropriate and properly fitted PPE suitable for protection from these hazards and ensuring that affected employees use it?

  Safe

  At Risk

  N/A

• Document entire discussion on this matter and include mandatory re-training if to come back to this project.

• Supervisor is to sign acknowledging the citation, violation, and corrective Actions to take place moving forward.

  Sign

• Select date

  Date

• Location

• Company Name

• Personnel Involved

• Add media

  Media

• Upcoming fall hazards addressed and planned for future proceedings.

  Safe

  At Risk

  N/A

• Has the individual using fall protection been properly trained?

  Safe

  At Risk

  N/A

• Employee is to be removed from this activity

• Supervisor is to be called to the area

• Document discussion and Corrective Actions

• Supervisor is to sign acknowledging the discussion and corrective Actions that are to take place.

  Sign

Additional information

Corrective Actions

• We're there any other hazards or safety issues that need Corrective Action?

  Yes

  No

  N/A

• Identify the hazard and document the Corrective Action:

• Add media

  Media

• Responsible Party(s):

• Is the Corrective Action being corrected?

  Yes

  No

  N/A

• Who is correcting this issue:

• Document what is to be taken place by whom is correcting the issue

• Assign here the deadline on when it will be corrected

  Date

• Supervisor is to sign acknowledging all what is above on this subject

  Sign

• Ensure a follow up on this issue

• STOP the work activity until a Corrective Action can be taken.

• Have the Supervisor come to the work area and discuss the issue

• Supervisor is to sign acknowledging this issue and that the work activity cannot continue until a Corrective Action takes place.

  Sign

• Assign a follow up on this issue

• Any Safety Citations pertaining to this subject will be in the Citation Section

• Observation of Fall Protection in use

  Yes

  No

  N/A
Netting

• Document Serial Number- Inspection Number

• Is it being properly used by your knowledge?

  Yes

  No

  N/A

• Rank the Netting on condition

  Excellent

  Great

  Satisfactory

  Concerns

  Hazardous

• Allow to proceed

• Identify the concerns and show to the Supervisor

  Media

• Document full discussion and outcome

• Supervisor acknowledging the discussion and final outcome

  Sign

• Have the employee come to a safe zone

• Call the Supervisor to the area or meet with the Supervisor along with the equipment

• Further discussion is to be made on inspections

• Explain to the Supervisor the equipment is no longer able to be of service and remove from service

• Document discussion with the Supervisor

• Supervisor signing acknowledging the discussion and corrective action

  Sign
Body Harness

• Document Serial Number- Inspection Number

• Is it being properly used by your knowledge?

  Yes

  No

  N/A

• Rank the Body Harness on condition

  Excellent

  Great

  Satisfactory

  Concerns

  Hazardous

• Allow to proceed

• Identify the concerns and show to the Supervisor

  Media

• Document full discussion and outcome

• Supervisor acknowledging the discussion and final outcome

  Sign

• Have the employee come to a safe zone

• Call the Supervisor to the area or meet with the Supervisor along with the equipment

• Further discussion is to be made on inspections

• Explain to the Supervisor the equipment is no longer able to be of service and remove from service

• Document discussion with the Supervisor

• Supervisor signing acknowledging the discussion and corrective action

  Sign
Lanyard

• Document Serial Number-Inspection Number

• Is it being properly used by your knowledge?

  Yes

  No

  N/A

• Rank the Lanyard on condition

  Excellent

  Great

  Satisfactory

  Concerns

  Hazardous

• Allow to proceed

• Identify the concerns and show to the Supervisor

  Media

• Document full discussion and outcome

• Supervisor acknowledging the discussion and final outcome

  Sign

• Have the employee come to a safe zone

• Call the Supervisor to the area or meet with the Supervisor along with the equipment

• Further discussion is to be made on inspections

• Explain to the Supervisor the equipment is no longer able to be of service and remove from service

• Document discussion with the Supervisor

• Supervisor signing acknowledging the discussion and corrective action

  Sign

• Retractable

Retractable

• Document Serial Number-Inspection Number

• Is it being properly used by your knowledge?

  Yes

  No

  N/A

• Rank the Retractable on condition

  Excellent

  Great

  Satisfactory

  Concerns

  Hazardous

• Allow to proceed

• Identify the concerns and show to the Supervisor

  Media

• Document full discussion and outcome

• Supervisor acknowledging the discussion and final outcome

  Sign

• Have the employee come to a safe zone

• Call the Supervisor to the area or meet with the Supervisor along with the equipment

• Further discussion is to be made on inspections

• Explain to the Supervisor the equipment is no longer able to be of service and remove from service

• Document discussion with the Supervisor

• Supervisor signing acknowledging the discussion and corrective action

  Sign
Rope/Rope Grab

• Document Serial Number-Inspection Number

• Is it being properly used by your knowledge?

  Yes

  No

  N/A

• Rank Rope- Rope Grab on condition

  Excellent

  Great

  Satisfactory

  Concerns

  Hazardous

• Allow to proceed

• Identify the concerns and show to the Supervisor

  Media

• Document full discussion and outcome

• Supervisor acknowledging the discussion and final outcome

  Sign

• Have the employee come to a safe zone

• Call the Supervisor to the area or meet with the Supervisor along with the equipment

• Further discussion is to be made on inspections

• Explain to the Supervisor the equipment is no longer able to be of service and remove from service

• Document discussion with the Supervisor

• Supervisor signing acknowledging the discussion and corrective action

  Sign
Concrete Anchor

• Document Serial Number-Inspection Number

• Is it being properly used by your knowledge?

  Yes

  No

  N/A

• Rank Concrete Anchor on condition

  Excellent

  Great

  Satisfactory

  Concerns

  Hazardous

• Allow to proceed

• Identify the concerns and show to the Supervisor

  Media

• Document full discussion and outcome

• Supervisor acknowledging the discussion and final outcome

  Sign

• Have the employee come to a safe zone

• Call the Supervisor to the area or meet with the Supervisor along with the equipment

• Further discussion is to be made on inspections

• Explain to the Supervisor the equipment is no longer able to be of service and remove from service

• Document discussion with the Supervisor

• Supervisor signing acknowledging the discussion and corrective action

  Sign

• Dyna-line (Horizontal Lifeline)

Dyna-line

• Document Serial Number-Inspection Number

• Is it being properly used by your knowledge?

  Yes

  No

  N/A

• Rank Dyna-line on condition

  Excellent

  Great

  Satisfactory

  Concerns

  Hazardous

• Allow to proceed

• Identify the concerns and show to the Supervisor

  Media

• Document full discussion and outcome

• Supervisor acknowledging the discussion and final outcome

  Sign

• Have the employee come to a safe zone

• Call the Supervisor to the area or meet with the Supervisor along with the equipment

• Further discussion is to be made on inspections

• Explain to the Supervisor the equipment is no longer able to be of service and remove from service

• Document discussion with the Supervisor

• Supervisor signing acknowledging the discussion and corrective action

  Sign
Other Fall Protection-Prevention-Arrest Equipment

• Name of Equipment?

Corrective Actions

• We're there any other hazards or safety issues in need of Corrective Action?

  Yes

  No

  N/A

• Identify the hazard and document the Corrective Action:

• If hazards or the likelihood of hazards are found, are Supervisors and Foremen selecting appropriate and properly fitted PPE suitable for protection from these hazards and ensuring that affected employees use it?

  Safe

  At Risk

  N/A

• Is it being properly used by your knowledge?

  Yes

  No

  N/A

• Rank Equipment on condition

  Excellent

  Great

  Satisfactory

  Concerns

  Hazardous

• Allow to proceed

• Identify the concerns and show to the Supervisor

  Media

• Document full discussion and outcome

• Supervisor acknowledging the discussion and final outcome

  Sign

• Have the employee come to a safe zone

• Call the Supervisor to the area or meet with the Supervisor along with the equipment

• Further discussion is to be made on inspections

• Explain to the Supervisor the equipment is no longer able to be of service and remove from service

• Document discussion with the Supervisor

• Supervisor signing acknowledging the discussion and corrective action

  Sign

Additional information

Corrective Actions

• We're there any other hazards or safety issues that need Corrective Action?

  Yes

  No

  N/A

• Identify the hazard and document the Corrective Action:

• Add media

  Media

• Responsible Party(s):

• Is the Corrective Action being corrected?

  Yes

  No

  N/A

• Who is correcting this issue:

• Document what is to be taken place by whom is correcting the issue

• Assign here the deadline on when it will be corrected

  Date

• Supervisor is to sign acknowledging all what is above on this subject

  Sign

• Ensure a follow up on this issue

• STOP the work activity until a Corrective Action can be taken.

• Have the Supervisor come to the work area and discuss the issue

• Supervisor is to sign acknowledging this issue and that the work activity cannot continue until a Corrective Action takes place.

  Sign

• Assign a follow up on this issue

• Any Safety Citations pertaining to this subject will be in the Citation Section

• Did you inspect any hand tool today?

  Yes

  No

  N/A
Hand Tool

• If broken, cracked, or re fabricated it is to be removed from service.

• Is the hand tool in satisfactory conditon

  Safe

  At Risk

  N/A

• Guards are being utilized?

  Safe

  At Risk

  N/A

• Guards are not being rigged and checked regularly?

  Safe

  At Risk

  N/A

• Is the tool being used properly for the job task?

  Safe

  At Risk

  N/A

• Did you inspect a power tool today?

  Yes

  No

  N/A
Power Tool

• Is the cord on the tool free from damage?

  Safe

  At Risk

  N/A

• Is a Ground Fault Circuit Interrupter being utilized for the power tool?

  Safe

  At Risk

  N/A

• Is it free of damage or defects?

  Safe

  At Risk

  N/A

• Is it double insulated or three prong?

  Safe

  At Risk

  N/A

• Did you inspect any machinery-equipment today?

  Yes

  No

  N/A

• Is there any damage or defects with the equipment?

  Safe

  At Risk

  N/A

• Is equipment and machinery securely placed and anchored to prevent tipping or other movement that could result in personal injury?

  Safe

  At Risk

  N/A

• Is all machinery and equipment kept clean and properly maintained?

  Safe

  At Risk

  N/A

• Document the corrective action taken.

Powder Actuated Tools

• Powder Actuated Tools

Powder Actuated Tool

• Are employees who operate powdered actuated tools trained in their use and required to carry valid operator's card?

  Safe

  At Risk

  N/A

• Are powdered actuated tools left unloaded until they are ready to be used?

  Safe

  At Risk

  N/A

• Are powdered actuated tools inspected for obstructions or defects each day before use?

  Safe

  At Risk

  N/A

• Are methods provided to protect the operator and other employees in the machine area from hazards created at the point of operation, ongoing nip points, rotating parts, flying chips, and sparks?

  Safe

  At Risk

  N/A

Additional Information

Corrective Actions

• We're there any other hazards or safety issues that need Corrective Action?

  Yes

  No

  N/A

• Identify the hazard and document the Corrective Action:

• Add media

  Media

• Responsible Party(s):

• Is the Corrective Action being corrected?

  Yes

  No

  N/A

• Who is correcting this issue:

• Document what is to be taken place by whom is correcting the issue

• Assign here the deadline on when it will be corrected

  Date

• Supervisor is to sign acknowledging all what is above on this subject

  Sign

• Ensure a follow up on this issue

• STOP the work activity until a Corrective Action can be taken.

• Have the Supervisor come to the work area and discuss the issue

• Supervisor is to sign acknowledging this issue and that the work activity cannot continue until a Corrective Action takes place.

  Sign

• Assign a follow up on this issue

• Any Safety Citations pertaining to this subject will be in the Citation Section

Equipment

• Identify the Equipment

  Select Skid Steer Backhoe Forklift-Lull Scissor Lift Aerial-Boom Lift Other None

  • Skid Steer
  • Backhoe
  • Forklift-Lull
  • Scissor Lift
  • Aerial-Boom Lift
  • Other
  • None

• Identify the Equipment

• Has the inspection been conducted by the operator?

  Safe

  At Risk

  N/A

• Are there any concerns with this equipment to take out of service?

  Yes

  No

  N/A

• Is the operator trained on how to operate this equipment? (Certification or authorization from the company)

  Safe

  At Risk

  N/A

• Has the inspection been conducted by the operator?

  Safe

  At Risk

  N/A

• Are there any concerns with this equipment to take out of service?

  Yes

  No

  N/A

• Is the operator trained on how to operate this equipment? (Certification or authorization from the company)

  Safe

  At Risk

  N/A

• Has the inspection been conducted by the operator?

  Safe

  At Risk

  N/A

• Are there any concerns with this equipment to take out of service?

  Yes

  No

  N/A

• Is the operator trained on how to operate this equipment? (Certification or authorization from the company)

  Safe

  At Risk

  N/A

• Are all personnel in the lift wearing Fall Restraint gear?

  Safe

  At Risk

  N/A

• STOP THE ACTIVITY IMMEDIATELY

• Find out if all personnel on the lift are sufficiently trained.

• Fall Hazards are an immediate 3 day suspension.

• Call there Supervisor to the area

• Location

• Select date

  Date
Employee

• Employee Name

• Company

• Has the employee been reprimanded before?

  Safe

  At Risk

  N/A

• Issue a three day suspension and mandatory re-training

• Take a picture of the citation

  Media

• Document here the discussion with the Supervisor.

• Supervisor is to sign acknowledging the citation and the mandatory training that must be conducted prior to doing any activities with this equipment.

  Sign

• Are there any recognized issues while the lift is being operated?

  Safe

  At Risk

  N/A

• Is this being corrected?

  Safe

  At Risk

  N/A

• Is a barricade or spotter used when needed during operation ( Includes under the basket)?

  Safe

  At Risk

  N/A

• Location

• Select date

  Date

• Employee operating the lift

• Stop the work activity and have the employee perform the inspection

• Have you discussed with this employee in the past about this issue?

  Yes

  No

  N/A

• Have the Supervisor come to the area

• Document discussion with the Supervisor pertaining to this issue.

• Supervisor is to sign acknowledging the issue and corrective action.

  Sign

• Has the Pre-Start Aerial Lift Inspection Log been conducted for this lift by the operator?

  Safe

  At Risk

  N/A

• Location

• Select date

  Date

• Employee operating the lift

• Stop the work activity and have the employee perform the inspection

• Have you discussed with this employee in the past about this issue?

  Yes

  No

  N/A

• Have the Supervisor come to the area

• Document discussion with the Supervisor pertaining to this issue.

• Supervisor is to sign acknowledging the issue and corrective action.

  Sign

• Are personnel conducting free-rigging?

  Safe

  At Risk

  N/A

• Location

• Select date

  Date

• Employee operating the lift

• Stop the work activity and have the employee perform the inspection

• Have you discussed with this employee in the past about this issue?

  Yes

  No

  N/A

• Have the Supervisor come to the area

• Document discussion with the Supervisor pertaining to this issue.

• Supervisor is to sign acknowledging the issue and corrective action.

  Sign

• Is the Operator qualified or authorized by the employer to operate the equipment?

  Safe

  At Risk

  N/A

• Location

• Select date

  Date

• Employee operating the lift

• Stop the work activity and have the employee perform the inspection

• Have you discussed with this employee in the past about this issue?

  Yes

  No

  N/A

• Have the Supervisor come to the area

• Document discussion with the Supervisor pertaining to this issue.

• Supervisor is to sign acknowledging the issue and corrective action.

  Sign

• Is the Operator wearing their seatbelt?

  Safe

  At Risk

  N/A

• Location

• Select date

  Date

• Employee operating the lift

• Stop the work activity and have the employee perform the inspection

• Have you discussed with this employee in the past about this issue?

  Yes

  No

  N/A

• Have the Supervisor come to the area

• Document discussion with the Supervisor pertaining to this issue.

• Has the Pre-Start Aerial Lift Inspection Log been conducted for all Aerial Lifts approached and used by personnel?

  Safe

  At Risk

  N/A

• Supervisor is to sign acknowledging the issue and corrective action.

  Sign

• Is a Spotter being utilized when the operators view is obstructed or in need of assistance?

  Safe

  At Risk

  N/A

• Stop the work activity and have the Supervisor come to the area to address the issue.

• Has the Forklift been inspected prior to use?

  Safe

  At Risk

  N/A

• Location

• Select date

  Date

• Employee operating the lift

• Stop the work activity and have the employee perform the inspection

• Have you discussed with this employee in the past about this issue?

  Yes

  No

  N/A

• Have the Supervisor come to the area

• Document discussion with the Supervisor pertaining to this issue.

• Supervisor is to sign acknowledging the issue and corrective action.

  Sign

• Anything additional?

  Yes

  No

  N/A

• Is the Operator qualified or authorized by the employer to operate the equipment?

  Safe

  At Risk

  N/A

• Location

• Select date

  Date

• Employee operating the lift

• Stop the work activity and have the employee perform the inspection

• Have you discussed with this employee in the past about this issue?

  Yes

  No

  N/A

• Have the Supervisor come to the area

• Document discussion with the Supervisor pertaining to this issue.

• Supervisor is to sign acknowledging the issue and corrective action.

  Sign

• Is a barricade or spotter used when needed during operation?

  Safe

  At Risk

  N/A

• Location

• Select date

  Date

• Employee operating the lift

• Stop the work activity and have the employee perform the inspection

• Have you discussed with this employee in the past about this issue?

  Yes

  No

  N/A

• Have the Supervisor come to the area

• Document discussion with the Supervisor pertaining to this issue.

• Supervisor is to sign acknowledging the issue and corrective action.

  Sign

• Has the Pre-Start Scissor Lift Inspection Log been conducted for this Scissor Lift by the personnel?

  Safe

  At Risk

  N/A

• Location

• Select date

  Date

• Employee operating the lift

• Stop the work activity and have the employee perform the inspection

• Have you discussed with this employee in the past about this issue?

  Yes

  No

  N/A

• Have the Supervisor come to the area

• Document discussion with the Supervisor pertaining to this issue.

• Supervisor is to sign acknowledging the issue and corrective action.

  Sign

• Anything additional

  Yes

  No

  N/A

Roadways and Traffic

• Did you witness any Road activities

  Yes

  No

  N/A

• Are flagmen properly trained for DOT regulations and have the qualification/certification up to date to perform the task?

  Safe

  At Risk

  N/A

• Are proper PPE worn for the task?

  Safe

  At Risk

  N/A

• Are proper communication methods taking place when directing traffic?

  Safe

  At Risk

  N/A

• Are paddles at the proper height for visibility?

  Safe

  At Risk

  N/A

• Are manhole covers, trench covers and similar covers, and their supports designed to carry a truck rear axle load of at least 20,000 lbs. (9,072 kilograms) when located in roadways and subject to vehicle traffic?

  Safe

  At Risk

  N/A

Additional Information

Corrective Actions

• We're there any other hazards or safety issues that need Corrective Action?

  Yes

  No

  N/A

• Identify the hazard and document the Corrective Action:

• Add media

  Media

• Responsible Party(s):

• Is the Corrective Action being corrected?

  Yes

  No

  N/A

• Who is correcting this issue:

• Document what is to be taken place by whom is correcting the issue

• Assign here the deadline on when it will be corrected

  Date

• Supervisor is to sign acknowledging all what is above on this subject

  Sign

• Ensure a follow up on this issue

• STOP the work activity until a Corrective Action can be taken.

• Have the Supervisor come to the work area and discuss the issue

• Supervisor is to sign acknowledging this issue and that the work activity cannot continue until a Corrective Action takes place.

  Sign

• Assign a follow up on this issue

• Any Safety Citations pertaining to this subject will be in the Citation Section

• Did you observe a Crane operation today pertaining to our work?

  Yes

  No

  N/A

Cranes

• Crane Operators are licensed with the state and or local jurisdiction?

  Safe

  At Risk

  N/A

• Crane Inspection Log kept up to date with routine inspections?

  Safe

  At Risk

  N/A

• Is the manual on-site?

  Safe

  At Risk

  N/A

• Accessible areas within the swing radius of the crane barricaded to prevent employee / pedestrian access/exposure?

  Safe

  At Risk

  N/A

• Did you observe a Rigging operation in any manner?

  Yes

  No

  N/A

Qualified Rigger / Signal Person

• Is an illustration of ANSI hand signals posted at the job-site?

  Safe

  At Risk

  N/A

• Are the personnel rigging and signaling the load qualified?

  Safe

  At Risk

  N/A

• Is there clear communication with the Operator?

  Safe

  At Risk

  N/A

• Are the slings, spreaders, and any shackles used for rigging inspected before being used on the job-site?

  Safe

  At Risk

  N/A

• Are the safety latches inspected and satisfactory?

  Safe

  At Risk

  N/A

• Is the one eye per hook method being implemented?

  Safe

  At Risk

  N/A

• Are tag-lines being used on every load?

  Safe

  At Risk

  N/A

• Is a warning sound blown on every load?

  Safe

  At Risk

  N/A

• Any additional information on this subject?

  Yes

  No

  N/A

Additional information

Corrective Actions

• We're there any other hazards or safety issues that need Corrective Action?

  Yes

  No

  N/A

• Identify the hazard and document the Corrective Action:

• Add media

  Media

• Responsible Party(s):

• Is the Corrective Action being corrected?

  Yes

  No

  N/A

• Who is correcting this issue:

• Document what is to be taken place by whom is correcting the issue

• Assign here the deadline on when it will be corrected

  Date

• Supervisor is to sign acknowledging all what is above on this subject

  Sign

• Ensure a follow up on this issue

• STOP the work activity until a Corrective Action can be taken.

• Have the Supervisor come to the work area and discuss the issue

• Supervisor is to sign acknowledging this issue and that the work activity cannot continue until a Corrective Action takes place.

  Sign

• Assign a follow up on this issue

• Any Safety Citations pertaining to this subject will be in the Citation Section

• Did you witness any Excavation activities today?

  Yes

  No

  N/A

• Is the underground installation accounted for by contacting the known local number?

  Safe

  At Risk

  N/A

• Is a competent person for excavations on-site?

  Safe

  At Risk

  N/A

• Name of Competent Person

• Stop all tasks until the Competent Person is back in the area.

• Is there safe access / egress provided from the excavation and travel distance is not exceeding 25 ft

  Safe

  At Risk

  N/A

• Are daily inspections along with change due to subject matters such as rain being conducted by a competent person?

  Safe

  At Risk

  N/A

• If not are proper procedures being taken to address and correct the hazard?

  Safe

  At Risk

  N/A

• Is the excavation or trench free of water?

  Safe

  At Risk

  N/A

• Is the excavation sloped or shored properly as per the soil type (Solid Rock, Type A., Type B., Type C.)?

  Safe

  At Risk

  N/A

Trench Box

Trench Box

• Was a trench box involved with this excavation?

  Yes

  No

  N/A

• If a trench box is being used is it a manufactured design?

  Safe

  At Risk

  N/A

• Is documentation provided on how to properly install and the designed strength?

  Safe

  At Risk

  N/A

• Has proper training been conducted ?

  Safe

  At Risk

  N/A

• Steel toe protection if using tamps?

  Safe

  At Risk

  N/A

Additional information

Corrective Actions

• We're there any other hazards or safety issues that need Corrective Action?

  Yes

  No

  N/A

• Identify the hazard and document the Corrective Action:

• Add media

  Media

• Responsible Party(s):

• Is the Corrective Action being corrected?

  Yes

  No

  N/A

• Who is correcting this issue:

• Document what is to be taken place by whom is correcting the issue

• Assign here the deadline on when it will be corrected

  Date

• Supervisor is to sign acknowledging all what is above on this subject

  Sign

• Ensure a follow up on this issue

• STOP the work activity until a Corrective Action can be taken.

• Have the Supervisor come to the work area and discuss the issue

• Supervisor is to sign acknowledging this issue and that the work activity cannot continue until a Corrective Action takes place.

  Sign

• Assign a follow up on this issue

• Any Safety Citations pertaining to this subject will be in the Citation Section

Outrigger

• Did you observe an Outrigger or a trade of ours using a outrigger?

  Yes

  No

  N/A

• Are guardrails installed on all three exposed sides?

  Safe

  At Risk

  N/A

• Are CAZ signs with the line up to prevent unauthorized personnel?

  Safe

  At Risk

  N/A

• Is the area the Outrigger is moving from and next expected area barricaded to prevent unauthorized personnel?

  Safe

  At Risk

  N/A

• When and if relocating are Spotters on the ground with area barricaded?

  Safe

  At Risk

  N/A

Additional information

Corrective Actions

• We're there any other hazards or safety issues that need Corrective Action?

  Yes

  No

  N/A

• Identify the hazard and document the Corrective Action:

• Add media

  Media

• Responsible Party(s):

• Is the Corrective Action being corrected?

  Yes

  No

  N/A

• Who is correcting this issue:

• Document what is to be taken place by whom is correcting the issue

• Assign here the deadline on when it will be corrected

  Date

• Supervisor is to sign acknowledging all what is above on this subject

  Sign

• Ensure a follow up on this issue

• STOP the work activity until a Corrective Action can be taken.

• Have the Supervisor come to the work area and discuss the issue

• Supervisor is to sign acknowledging this issue and that the work activity cannot continue until a Corrective Action takes place.

  Sign

• Assign a follow up on this issue

• Any Safety Citations pertaining to this subject will be in the Citation Section

Ladders

Ladder Inspection

• Inspection of a ladder?

  Yes

  No

  N/A

• Type of ladder

  A-Frame Ladder

  Extension Ladder

  Job-Built Ladder

  Other

• Identify the type of ladder

• Is it free from damage or any defects?

  Safe

  At Risk

  N/A

• Is the ladder Inspected prior to use (Inspection Tag)?

  Safe

  At Risk

  N/A

• Identify here if there are any concerns with this ladder or positive methods being implemented.

• Is the ladder Inspected prior to use (Inspection Tag)?

  Safe

  At Risk

  N/A

• Is it free from damage or any defects?

  Safe

  At Risk

  N/A

• Is there a platform?

  Yes

  No

  N/A

• Are the landing platforms secure and free from any damage or defects?

  Safe

  At Risk

  N/A

• Is it fully open when in use?

  Safe

  At Risk

  N/A

• Is it the proper size for the task?

  Safe

  At Risk

  N/A

• Are all labels on the ladder and legible?

  Safe

  At Risk

  N/A

• If exposed to a fall hazard, is the worker using proper fall protection?

  Safe

  At Risk

  N/A

• Is the top step of the ladder being used?

  Safe

  At Risk

  N/A

• Is three points of contact being utilized?

  Safe

  At Risk

  N/A

• Is it being used in any other unsafe manner?

  Yes

  No

  N/A

• Is the ladder secure at the top and the bottom?

  Safe

  At Risk

  N/A

• Is there a clear access / egress to the ladder?

  Safe

  At Risk

  N/A

• Are offset guardrails at the ladder way?

  Safe

  At Risk

  N/A

• Is an attachment used for the 36 inch extension past the landing?

  Safe

  At Risk

  N/A

• Any visible damage?

  Safe

  At Risk

  N/A

• Are side-rails extending 36 inches above the landing platform?

  Safe

  At Risk

  N/A

• Any visible damage?

  Safe

  At Risk

  N/A

• Are offset guardrails at the ladder way?

  Safe

  At Risk

  N/A

• Is there a clear access / egress to the ladder?

  Safe

  At Risk

  N/A

• Is the ladder secure at the top and the bottom?

  Safe

  At Risk

  N/A

• Is the ladder built by the correct standard? https://www.osha.gov/Publications/OSHA3661.pdf

  Yes

  No

  N/A

Stairway

Stairs

• Inspection of Stairs?

  Yes

  No

  N/A

• Location

• Select date

  Date

• Do standard stair rails or handrails on all stairways have at least four risers?

  Safe

  At Risk

  N/A

• Are steps slip resistant?

  Safe

  At Risk

  N/A

• Are stairway handrails located between 30 inches and 34 inches above the leading-edge of stair treads?

  Safe

  At Risk

  N/A

• Do stairs have landing platforms not less than 30 inches (76.20 centimeters) in the direction of travel and extend 22 inches (55.88 centimeters) in width at every 12 feet (3.6576 meters) or less of vertical rise?

  Safe

  At Risk

  N/A

• Are stairway handrails capable of withstanding a load of 200 lbs. applied within 2 inches of the top edge in any downward or outward direction?

  Safe

  At Risk

  N/A

• Do stairway landings have a dimension measured in the direction of travel at least equal to the width of the stairway?

  Safe

  At Risk

  N/A

• Are the access entry and exit ways clear for safe entry and exiting?

  Safe

  At Risk

  N/A

• Do stairs angle no more than 50 degrees and no less than 30 degrees?

  Safe

  At Risk

  N/A

• Are stairways at least 22 inches wide (55.88 centimeters)?

  Safe

  At Risk

  N/A

Additional information

Corrective Actions

• We're there any other hazards or safety issues that need Corrective Action?

  Yes

  No

  N/A

• Identify the hazard and document the Corrective Action:

• Add media

  Media

• Responsible Party(s):

• Is the Corrective Action being corrected?

  Yes

  No

  N/A

• Who is correcting this issue:

• Document what is to be taken place by whom is correcting the issue

• Assign here the deadline on when it will be corrected

  Date

• Supervisor is to sign acknowledging all what is above on this subject

  Sign

• Ensure a follow up on this issue

• STOP the work activity until a Corrective Action can be taken.

• Have the Supervisor come to the work area and discuss the issue

• Supervisor is to sign acknowledging this issue and that the work activity cannot continue until a Corrective Action takes place.

  Sign

• Assign a follow up on this issue

• Any Safety Citations pertaining to this subject will be in the Citation Section

• Did you observe or go over a confined space operation?

  Yes

  No

  N/A

• Is a permit completed before any other steps?

  Safe

  At Risk

  N/A

• Select date

  Date

• Are rescue measures in place?

  Safe

  At Risk

  N/A

• Is an air monitor used to check the air in the confined space prior to entry?

  Safe

  At Risk

  N/A

• Is there proper access into the area?

  Safe

  At Risk

  N/A

• Are Spotters used to check employees in the area?

  Safe

  At Risk

  N/A

• Is there clear communication for if any issues rise?

  Safe

  At Risk

  N/A

• Is the atmosphere in the confined space being continuously monitored?

  Safe

  At Risk

  N/A

• Is there proper ventilation?

  Yes

  No

  N/A

Additional information

Corrective Actions

• We're there any other hazards or safety issues that need Corrective Action?

  Yes

  No

  N/A

• Identify the hazard and document the Corrective Action:

• Add media

  Media

• Responsible Party(s):

• Is the Corrective Action being corrected?

  Yes

  No

  N/A

• Who is correcting this issue:

• Document what is to be taken place by whom is correcting the issue

• Assign here the deadline on when it will be corrected

  Date

• Supervisor is to sign acknowledging all what is above on this subject

  Sign

• Ensure a follow up on this issue

• STOP the work activity until a Corrective Action can be taken.

• Have the Supervisor come to the work area and discuss the issue

• Supervisor is to sign acknowledging this issue and that the work activity cannot continue until a Corrective Action takes place.

  Sign

• Assign a follow up on this issue

• Any Safety Citations pertaining to this subject will be in the Citation Section

Chemical

• Have you come across a chemical in use?

  Yes

  No

  N/A

• Identify the chemical

• Company Responsible for the chemical

• Location

• Select date

  Date

• Is the Safety Data Sheet in the area with the chemical?

  Yes

  No

  N/A

• Is the chemical stored properly?

  Yes

  No

  N/A

• Enter image

  Media

• Continue your audit

• Stop the activity and have the company

• Is a spill kit available?

  Safe

  At Risk

  N/A

• Has personnel conducting a task with a chemical, read and understand the safety data sheets of that chemical?

  Safe

  At Risk

  N/A

• STOP the activity and have the Supervisor come to the work area

• Does the Supervisor know and understand the Safety Data Sheets of that chemical?

  Safe

  At Risk

  N/A

• Make sure the Supervisor understands all employees are in need to fully understand the chemical they are working with.

• Supervisor to sign acknowledging this discussion.

  Sign
Employee acknowledgment

• Employee signature acknowledging having to understand the chemical before handling it.

  Sign

• Can the employees tell you the pictograms and the signal word on the SDS?

  Yes

  No

  N/A

• Were they correct?

  Safe

  At Risk

  N/A

• Go over the Safety Data Sheets with them.

Additional Information

Corrective Actions

• We're there any other hazards or safety issues that need Corrective Action?

  Yes

  No

  N/A

• Identify the hazard and document the Corrective Action:

• Add media

  Media

• Responsible Party(s):

• Is the Corrective Action being corrected?

  Yes

  No

  N/A

• Who is correcting this issue:

• Document what is to be taken place by whom is correcting the issue

• Assign here the deadline on when it will be corrected

  Date

• Supervisor is to sign acknowledging all what is above on this subject

  Sign

• Ensure a follow up on this issue

• STOP the work activity until a Corrective Action can be taken.

• Have the Supervisor come to the work area and discuss the issue

• Supervisor is to sign acknowledging this issue and that the work activity cannot continue until a Corrective Action takes place.

  Sign

• Assign a follow up on this issue

Citations written today.

Safety Citation

• Did you write any citations today?

  Yes

  No

  N/A

• Why the citation was issued?

• Name of person receiveing citation

• Company Name

• Location

• Date/Time

  Date

• Has the person received citations in the past?

  Yes

  No

  N/A

• How many has the person received?

Date & Time

• Select date

  Date

• What was the severity of the citation?

• What was the disciplinary action taken with employee?

• Supervisor's name

• Insert discussion had with the Supervisor

• Signature of Supervisor

  Sign

• Any Safety Citations pertaining to this subject will be in the Citation Section

• Are there any additional comments or issues that are in need to be added?

  Yes

  No

  N/A
Additional Information

• Media

• Select date

  Date