Cal-Safety

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Paper Work and Qualifications

• 1 JSA Completed/Meaning Full Conversation

  Safe

  At Risk

  N/A

• 2 Proper Permit Completed

  Safe

  At Risk

  N/A

• 3 Meet & Greet Procedures/EAP

  Safe

  At Risk

  N/A

• 4 Pre-Job Safety Meeting

  Safe

  At Risk

  N/A

• 5 Designated Smoking Area

  Safe

  At Risk

  N/A

• 6 Employee Training Documentation

  Safe

  At Risk

  N/A

• 7 Operators Trained & Certified

  Safe

  At Risk

  N/A

• Safety Data Sheet

  Yes

  No

  N/A

• Written Safety Programs

  Yes

  No

  N/A

• 8 Drivers License

  Safe

  At Risk

  N/A

• 9 First Aid/CPR certified

  Safe

  At Risk

  N/A

• Employee Certification Requirement

  Yes

  No

  N/A

Standard Job Safety

• 10 Minimum PPE Worn

  Safe

  At Risk

  N/A

• 11 H2S Monitor/Gas Monitor

  Safe

  At Risk

  N/A

• 12 First Aid Kits & Inspection

  Safe

  At Risk

  N/A

• 13 Fire Extinguisher & Inspection

  Safe

  At Risk

  N/A

• 14 Heat Illness Prevention

  Safe

  At Risk

  N/A

• 15 Fall Protection

  Safe

  At Risk

  N/A

• 16 Hearing Protection @ 85 dec.

  Safe

  At Risk

  N/A

• 17 House Keeping

  Safe

  At Risk

  N/A

• 18 Proper Tools for the Job

  Safe

  At Risk

  N/A

• 19 Tools In Good Condition

  Safe

  At Risk

  N/A

Specific Job Task Safety

• 20 Energy Isolation/ LOTO

  Safe

  At Risk

  N/A

• 21 Traffic Control

  Safe

  At Risk

  N/A

• 22 Proper Lifting Techniques (mechanical means/buddy system, flex the knees

  Safe

  At Risk

  N/A

• 23 Power LIne Avoidance

  Safe

  At Risk

  N/A

Equipment Clean and in Order

• 24 Guards on Equipment

  Safe

  At Risk

  N/A

• 25 In Cab Inspection

  Safe

  At Risk

  N/A

• 26 Truck Bed/Tool Box

  Safe

  At Risk

  N/A

Emergency Action Plan

• Exit Routes and Muster Points

  Yes

  No

  N/A

• Occupational Doctor Facility

  Yes

  No

  N/A

• Confined Space Rescue

  Yes

  No

  N/A

• Audited Signature

  Sign

• Auditor signature

  Sign

• Select any on site hazards

  Select Pre-Job Inspection Proper Permit Completed for the Job Task Lock Out Tag Out PPE Gloves H2S/Monitors Hearing Protection Fall Protection Walking Working Services House Keeping Tools Used for their Purpose Power Tools Crane Operation Tag Line Vehicles Lifting/Pushing/Pulling/Carrying Line of Fire Avoid being Pinched or pinned Climbing Grinder Guard Equipment Condition Combustibles Clear NONE

  • Pre-Job Inspection
  • Proper Permit Completed for the Job Task
  • Lock Out Tag Out
  • PPE
  • Gloves
  • H2S/Monitors
  • Hearing Protection
  • Fall Protection
  • Walking Working Services
  • House Keeping
  • Tools Used for their Purpose
  • Power Tools
  • Crane Operation
  • Tag Line
  • Vehicles
  • Lifting/Pushing/Pulling/Carrying
  • Line of Fire
  • Avoid being Pinched or pinned
  • Climbing
  • Grinder Guard
  • Equipment Condition
  • Combustibles Clear
  • NONE

• Description of Hazard

• Include a photograph if possible

  Media

• Likely Severity Of Injury Should An Incident Occur

  Fatality

  Serious Injury

  Minor Injury

  First Aid Only

  Damage Equipment

• Risk Matrix

  

• Select Overall Risk Rating

  Extreme

  High

  Medium

  Low

• Auditor Signature

  Sign