• Client / Site

  • District

  • Conducted on

  • Prepared by

  • Location

Hard Hat

  • Take picture of your Hard Hat (mandatory)

  • Manufacturer?

  • Clean and Sanitary?

Hearing Protection

  • Take picture of your hearing protection (mandatory)

  • Type of hearing protection you have

  • Hearing protection is readily available

  • Clean and Sanitary?

Respiratory Protection

  • Take picture of your Respiratory Protection (mandatory)

  • Is this respirator North 7700?

  • Manufacturer?

  • Model Number?

  • Do you have a sufficient amount of canisters?

  • Take picture of your H2S Monitor

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

Eye and Face Protection

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

  • Type of Eye Protection?

  • Marked as ANSI Z.87 or CSA Z94.3?

  • Clean and Sanitary Eye Protection?

  • Type of Face Protection?

  • Clean and Sanitary Face Protection?

Hand Protection

  • Take picture of your Hand Protection (mandatory)

  • Clean and Sanitary Hand Protection?

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

Safety Footwear

  • Take picture of your Safety Footwear (mandatory)

  • Good Condition and Not Needing Repair?

  • Clean and Sanitary

  • Type of Footwear?

  • Appropriate for Hazards?

Fall Protection

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

  • Is the Harness and SRL readily available?

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

  • Is the Harness and SRL clean and serviceable?

Lifting Sling Inspection

  • Add Sling to Inspect

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

  • 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?

  • Will this sling be returned to service?

Follow Up

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

  • <>

  • Has deficiencies been addressed?

  • What was done to address deficiency?

  • Supervisor's Name and Signature?

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

  • Inspector's Name

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.