BOS PPE Inspection Form - local copy

• Client / Site

• District

  Select Appalachia Grande Prairie Leduc Midland North Dakota Rio Vista

  • Appalachia
  • Grande Prairie
  • Leduc
  • Midland
  • North Dakota
  • Rio Vista

• Conducted on

  Date

• Prepared by

• Location
  Address

Hard Hat

• Take picture of your Hard Hat (mandatory)

  Media

• Manufacturer?

• Clean and Sanitary?

  Yes

  No

  N/A

  Not Checked

Hearing Protection

• Take picture of your hearing protection (mandatory)

  Media

• Type of hearing protection you have

  Select Muffs Plugs

  • Muffs
  • Plugs

• Hearing protection is readily available

  Safe

  At Risk

  N/A

• Clean and Sanitary?

  Yes

  No

  N/A

  Not Checked

Respiratory Protection

• Take picture of your Respiratory Protection (mandatory)

  Media

• Is this respirator North 7700?

  Yes

  No

  N/A

• Manufacturer?

• Model Number?

• Do you have a sufficient amount of canisters?

  Yes

  No

  N/A

  Not Checked

• Take picture of your H2S Monitor

  Media

• Is the H2S monitor in good working order, been calibrated monthly, and bump tested daily at the start of shift?

  Yes

  No

  N/A

Eye and Face Protection

• Take picture of your Eye/Face protection (mandatory)

  Media

• Type of Eye Protection?

• Marked as ANSI Z.87 or CSA Z94.3?

  Yes

  No

  N/A

  Not Checked

• Clean and Sanitary Eye Protection?

  Yes

  No

  N/A

  Not Checked

• Type of Face Protection?

• Clean and Sanitary Face Protection?

  Yes

  No

  N/A

  Not Checked

Hand Protection

• Take picture of your Hand Protection (mandatory)

  Media

• Clean and Sanitary Hand Protection?

  Yes

  No

  N/A

  Not Checked

• Hand Protection is Safe and Does not Need Repairs (No Holes/Tears)?

  Yes

  No

  N/A

  Not Checked

Safety Footwear

• Take picture of your Safety Footwear (mandatory)

  Media

• Good Condition and Not Needing Repair?

  Yes

  No

  N/A

  Not Checked

• Clean and Sanitary

  Yes

  No

  N/A

  Not Checked

• Type of Footwear?

  Dunlop

  Other

• Appropriate for Hazards?

  Yes

  No

  N/A

  Not Checked

Fall Protection

• Take a picture of your Harness and SRL (mandatory)

  Media

• Is the Harness and SRL readily available?

  Yes

  No

  N/A

• Is the Harness and SRL free of cuts and/or frays?

  Yes

  No

  N/A

• Is the Harness and SRL clean and serviceable?

  Yes

  No

  N/A

Lifting Sling Inspection

• Add Sling to Inspect

Sling

• Take a picture of the lifting strap(s) on location (mandatory)

  Media

• Sling Identification Number

• Is the lifting strap free of Acid Burns, Melting or Charring, Snags, Punctures, Tears, Cuts, Broken Stitches, Worn Stitches, Distorted Fittings, Worn Fittings?

  Yes

  No

  N/A

• Will this sling be returned to service?

  Yes

  No

  N/A

Follow Up

• Is follow up needed? - If any deficiencies above that have not been addressed select "Yes"

  Yes

  No

  N/A

• <>
  <<>>
  

• Has deficiencies been addressed?

  Yes

  No

  N/A

• What was done to address deficiency?

• Supervisor's Name and Signature?

  Sign

Inspector and Employee Information

• Before signing I am agreeing that I have either: 1 - Fixed all deficiencies noted in this document, or 2 - Notified my supervisor on the deficiencies that I have not been able to fix.

• Employee's Name

  Sign

• Inspector's Name

  Sign