Information
-
Supervisor
-
Foreman
-
Date
-
Job No.
-
Location
-
Prepared by
Daily Safety & Pre-Task Planning
Daily Safety & Pre-Task Planning
-
Are Daily Safety & Pre-Task Planning forms being completed?
-
Is the work being done matching the form?
-
Why is not being completed?
-
Daily huddle completed?
-
Employee Comments
Comments
-
Name
-
Comments
Emergency
Emergency Plan
-
Do employees know of the emergency plan?
-
911 Confirmation
-
Clinic/Hospital Location
New Employees
-
Jobsite Orientation
-
Integration
-
New Employee Concerns
Concerns
-
Name
-
Concern
New Employee
New Employee
-
Have you completed job site orientation?
-
Are you being welcomed in/how are you fitting in?
-
Do you have any concerns?
New Employee
-
Have you completed job site orientation?
-
Are you being welcomed in/how are you fitting in?
-
Do you have any concerns?
New Employee
-
Have you completed job site orientation?
-
Are you being welcomed in/how are you fitting in?
-
Do you have any concerns?
TPR
TPR (Open Ended Questions)
-
Issues and Concerns?
Comment
-
Describe
Machinery
-
Lubricated?
-
Clean?
-
Seat belt?
-
Safety equipment?
-
Any issues with One Call or Operator Care?
-
Explain
Locates
Overhead
-
Power Lines
-
How far away (in ft.)?
-
Phone Lines?
Underground
-
Power Lines
-
How far away (in ft.)?
-
Phone Lines?
-
Fiber-optics?
-
Gas lines?
-
Water Lines?
-
Sewer Lines?
Traffic Control
-
Designated employee parking?
-
Picture
-
Suggestions for parking spots
-
Picture
-
Pedestrian Traffic Areas designated and guarded?
-
Picture
-
Haul Routes and/or Traffic Pattern in place?
-
Work zone signing/traffic control manual in place?
Trench Safety
-
Type of Soil Present
Which types? (check all that apply)
-
A
-
B
-
C
-
Is the trench safe?
-
Picture
-
Ladders within 25ft of employees?
-
Are employees aware of the rescue plan?
Chains and Slings
-
Chains and Slings
Equipment
-
What is the condition of the chains/slings?
-
Photos
-
Have the chains/slings been inspected and certified within the last year?
-
Date of last inspection
Employees
-
Are employees operating within the danger zone/swing zone of equipment?
-
Are employees aware of swing zone/danger zone?
Cranes
Crane
-
Is there a Certified Crane Operator (CCO)?
-
Load chart and lift chart located in the crane?
-
Condition of the crane?
-
Are employees working underneath crane loads?
-
Picture
Pile Driver
-
Is the driver/hammer in good condition?
-
Are the manufacturing plates attached and inspected?
-
Date of Last Inspection
Placing Rebar
-
Is rebar capped or properly covered by 2x4s?
-
Is the rebar placed correctly?
-
Is the rebar bent/unusable?
Power/Hand Tools
Tool
-
Tool
-
Name of Tool
-
Proper Guarding on Tool?
-
Exterior Damage?
-
Describe
-
Picture
-
Are cord(s) cut, frayed, damaged?
-
Describe
-
Picture
PPE
-
Proper PPE worn? (select all that apply)
- Respirator
- Safety Glasses
- Face Shield
- Gloves
- Chaps
- Hearing Protection
- Safety toed shoes
Fall Protection
Lifts (Scissors, Aerial, Boom)
-
Lift
-
Lift #
-
Daily inspection complete?
-
Used correctly?
-
Damage?
-
Photo
-
Describe
Ladder
-
Lift
-
Daily inspection complete?
-
Used correctly?
-
Damage?
-
Photo
-
Describe
-
Tied off?
-
Temporary or Permanent?
Guardrail
-
Guardrail
-
Location
-
Damage?
-
Photo
-
Top rail, mid rail, and toe kick?
-
Top
-
Mid
-
Toeboard
Body Harness and Lanyards
-
Harness
-
Serial #
-
Daily inspection?
-
Damage?
-
Photo
Lanyard
-
Serial #
-
Daily inspection?
-
Damage?
-
Photo
Harness
-
Daily inspection?
-
Damage?
-
Photo
Harness
-
Daily inspection?
-
Damage?
-
Photo
Lift
-
Lift #
-
Daily inspection complete?
-
Used correctly?
-
Damage?
-
Photo
-
Describe
Concrete Pours
-
Has the concrete properly cured?
-
While curing, has the concrete been properly covered?
PPE
Are employees wearing....?
-
Safety Vests?
-
Are the vests in good condition (clean, reflective material visible, etc.)?
-
Safety glasses?
-
If grinding/cutting, are face shields also being worn?
-
Hearing protection (if required)?
-
Hard hats?
-
Are hard hats free from nicks, gouges, and is suspension inside hard hat adjusted properly?
-
Sun protection? (sunscreen, UV protective clothing)?
-
Seat belts on equipment being worn?
-
Fall protection (if required)?
Chain Saw Safety (if applicable)
-
Chaps being worn and fitted properly?
-
Hard hat?
-
Face shield and safety glasses being worn?
-
Hearing protection?
-
Gloves being worn?
Erosion Control
-
Erosion control measures in place?
-
Following SWPPP?
-
Photos
Cell Phone usage
-
Do employees have cell phones on their person?
-
Are cell phones being used during work hours?
Previous Job Site Inspection
-
Date of Last Job Site Inspection
-
Name of Supervisor
Finalization
-
Executive Safety Committee Member
- Trevor Duininck
- Chris Duininck
- Jason Duininck
- Judd Duininck
- Rick Maursetter
- Jeff Rettig
-
Select date
-
Add signature
-
Supervisor
-
Select date
-
Received copy?
-
Add signature