Title Page
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Job name
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Job number
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Conducted on
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Competent person
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Prepared by
General safety
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Did you start your day by stretching?
General information. Mark all that apply.
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What are the hazards associated with the job?
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Chemical burn
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Extreme weather
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Particles in eyes
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Over exertion
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Elevator load
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Falls over 6ft
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Over head work
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Pinch points
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Lead/asbestos
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Cranes/rigging
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Live utility work/electrical shock
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Using hazardous materials
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Trips/spills falls
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Fire/explosion
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Abrasion/cuts burns
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Cave ins
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Loud noise
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Sprains/strains
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Falling objects
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Vehicle traffic
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Power tools
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Other (explain)
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Have these hazards been explained to the employees?
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Considering your scheduled task for today, what specific steps will be taken to remain safe and efficient?
Personal protective equipment
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Fall protection
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Eye/face
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Respirator
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Hand
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Hearing
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Foot
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Coveralls
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Hard hat
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Class 2 safety vest
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Other types. (Specify)
Procedures/permits required
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Hot work
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Lockout/tag out
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Excavation
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Signs/barricades
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Confined space
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Crane lift
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Line break/hot tapping
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Utility shutdown
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Scaffolding
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Other (specify)
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Is fire watch attendant required?
Employee certification required
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Crane operator
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Forklift operator
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Mobile equipment operator
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Power actuated tool user
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Competent person
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CPR/AED/First aid
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Other (specify)
Tools and equipment
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User inspection is required on all tools, ladders, electrical cords, rigging and safety equipment. Has this been completed?
Hazardous materials
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Has the material storage area been identified and approved?
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Have sds been reviewed for health hazards prior to use?
Scaffolds/ladders
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Inspect all scaffolds/ladders before use. Has scaffold tag been signed?
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Does your ladder have a current inspection?
First aid and safety
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Identify below the location of the nearest first aid safety kit
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Are all employees aware of first aid location?
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Is first aid fully stocked and accessible?
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Is there a supply of drinking water on the roof?
House keeping
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Are trash receptacles available?
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Location?
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Was trash removal completed yesterday?
Fire protection
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Are flammable/combustible materials stored, separated, inspected and secured per the safety plan?
Fall protection
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Is fall protection required?
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Is an engineered system in place
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What type?
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Have all employees been instructed in its use?
Employees signature only
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Employee signature
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Employee signature
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Employee signature
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Employee signature
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Employee signature
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Employee signature
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Employee signature
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Employee signature
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Employee signature
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Employee signature
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Employee signature
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Employee signature
Foreman signature only
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Foreman signature