Bonness Inc.

• Job Name/Description

• Conducted on

  Date

• Prepared by

• Location
  Address

• Supervisor/Foreman

• # of EE's

• Unsafe Acts?

  Yes

  No

  N/A

• Applicable Photos

  Media

• Unsafe acts observed:

• Were corrective actions taken?

  Yes

  No

  N/A

• Corrective actions carried out:

• Unsafe Conditions?

  Yes

  No

  N/A

• Applicable Photos

  Media

• Unsafe conditions observed:

• Were corrective actions taken?

  Yes

  No

  N/A

• Corrective actions carried out:

• Housekeeping

  Ok/Compliant

  Not OK/Non-Compliant

  N/A

• Photos

  Media

• Corrective action taken

• Facilities Available and Maintained

  Ok/Compliant

  Not OK/Non-Compliant

  N/A

• Photos

  Media

• Corrective action taken

• Drinking Water

  Yes

  No

  N/A

• Cups Available

  Yes

  No

  N/A

• Sanitized Containers

  Yes

  No

  N/A

• Corrective action taken

• Personal Protective Equipment

  Ok/Compliant

  Not OK/Non-Compliant

  N/A

• Corrective action taken

• Accident Forms and Instructions

  Ok/Compliant

  Not OK/Non-Compliant

  N/A

• Corrective Actions

• First Aid Kit

  Yes

  No

  N/A

• Corrective Actions

• Hand Tools and Power Tools

  Ok/Compliant

  Not OK/Non-Compliant

  N/A

• Corrective Actions

• MOT and Equipment Protection

  Ok/Compliant

  Not OK/Non-Compliant

  N/A

• Corrective Actions

• Excavation

  Off

  On

• Protective System

  Ok/Compliant

  Not OK/Non-Compliant

  N/A

• Spoil > 2' from Excavation

  Ok/Compliant

  Not OK/Non-Compliant

  N/A

• Egress

  Ok/Compliant

  Not OK/Non-Compliant

  N/A

• Water Control

  Ok/Compliant

  Not OK/Non-Compliant

  N/A

• Utilities Identified/Marked

  Yes

  No

  N/A

• Competent Person

  Yes

  No

  N/A

• Corrective Actions

Equipment

• Lights/Horns Operating

  Yes

  No

  N/A

• Hoisting Equipment

  Ok/Compliant

  Not OK/Non-Compliant

  N/A

• Corrective Actions

• Additional Comments or Actions Taken

• Recommendations for Safety Improvement

• 5-minute Safety Huddle

  Yes

  No

  N/A

• Additional Notes

• Additional Site Photos

  Media