Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

  • Select date

  • Location/Work Description/Personnel

  • Work Zone Safety

  • 1. Actively Managing Work Area ?

  • Poor

  • Needs Improvement

  • Good

  • 2. Signs Flaggers and Police Details being used properly?

  • Yes

  • Needs improvement

  • No

  • Communication & Risk Assessment

  • 1. A complete, well-written, Job brief has been performed identifying the hazards and risks associated with the job and the steps put in place to reduce those risks. (Ie: proximity of energized lines, grounding, shoring, low hanging pipes, etc.)

  • Poor

  • Needs Improvement

  • Good

  • 2. Crew Members are focused on the task at hand and demonstrate a clear understanding of job hazards and conditions.

  • Poor

  • Needs Improvement

  • Good

  • Methods and Procedures

  • 1. Follows proper grounding procedures?

  • Yes

  • Needs Improvement

  • No

  • 2. Were required notifications and proper permits obtained?

  • Safe

  • Needs Improvement

  • Unsafe

  • 3. Were Three points of contact utilized?

  • Yes

  • Needs Improvement

  • No

  • 4. Is housekeeping of the trucks adequate?

  • Yes

  • Needs Improvement

  • No

  • 5. Is Proper PPE being utilized?

  • Good

  • Needs improvement

  • Poor

  • Work Practices

  • 1. Takes precautions and maintains a safe position when working.

  • Good

  • Needs Improvement

  • Poor

  • 2. uses equipment and tools in a way that protects them and others from danger?

  • Workplace environment

  • 1.Proper site preparation has been performed

  • Good

  • Needs Improvement

  • Poor

  • 2. 2-5-25 rule in place?

  • Yes

  • Needs improvement

  • No

  • 3. Equipment properly grounded

  • Good

  • Needs improvement

  • Poor

  • 4. Safety equipment accessible, inspected, fully stocked and utilized?

  • Good

  • Needs improvement

  • Poor

  • 5. Grounding procedures adhered to?

  • Yes

  • Needs Improvement

  • No

  • Excavation

  • 1. Has a dig safe number been assigned to the work site?

  • Yes

  • Needs improvement

  • No

  • 2. All underground facilities have been identified (ie gas, electric, telephone, water)

  • Good

  • Needs improvement

  • Poor

  • 3. Soil classification and protective systems have been identified and are in place.

  • Safe

  • Needs Improvement

  • Unsafe

  • 4. Proper grounding procedures adhered to?

  • Yes

  • Needs improvement

  • No

  • 5. All activity in workplace being performed in a safe manner?

  • Yes

  • Needs improvement

  • No

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.