Title Page

  • Job name

  • Job number

  • Conducted on

  • Competent person

  • Prepared by

General safety

  • Did you start your day by stretching?

General information. Mark all that apply.

  • What are the hazards associated with the job?

  • Chemical burn

  • Extreme weather

  • Particles in eyes

  • Over exertion

  • Elevator load

  • Falls over 6ft

  • Over head work

  • Pinch points

  • Lead/asbestos

  • Cranes/rigging

  • Live utility work/electrical shock

  • Using hazardous materials

  • Trips/spills falls

  • Fire/explosion

  • Abrasion/cuts burns

  • Cave ins

  • Loud noise

  • Sprains/strains

  • Falling objects

  • Vehicle traffic

  • Power tools

  • Other (explain)

  • Have these hazards been explained to the employees?

  • Considering your scheduled task for today, what specific steps will be taken to remain safe and efficient?

Personal protective equipment

  • Fall protection

  • Eye/face

  • Respirator

  • Hand

  • Hearing

  • Foot

  • Coveralls

  • Hard hat

  • Class 2 safety vest

  • Other types. (Specify)

Procedures/permits required

  • Hot work

  • Lockout/tag out

  • Excavation

  • Signs/barricades

  • Confined space

  • Crane lift

  • Line break/hot tapping

  • Utility shutdown

  • Scaffolding

  • Other (specify)

  • Is fire watch attendant required?

Employee certification required

  • Crane operator

  • Forklift operator

  • Mobile equipment operator

  • Power actuated tool user

  • Competent person

  • CPR/AED/First aid

  • Other (specify)

Tools and equipment

  • User inspection is required on all tools, ladders, electrical cords, rigging and safety equipment. Has this been completed?

Hazardous materials

  • Has the material storage area been identified and approved?

  • Have sds been reviewed for health hazards prior to use?

Scaffolds/ladders

  • Inspect all scaffolds/ladders before use. Has scaffold tag been signed?

  • Does your ladder have a current inspection?

First aid and safety

  • Identify below the location of the nearest first aid safety kit

  • Are all employees aware of first aid location?

  • Is first aid fully stocked and accessible?

  • Is there a supply of drinking water on the roof?

House keeping

  • Are trash receptacles available?

  • Location?

  • Was trash removal completed yesterday?

Fire protection

  • Are flammable/combustible materials stored, separated, inspected and secured per the safety plan?

Fall protection

  • Is fall protection required?

  • Is an engineered system in place

  • What type?

  • Have all employees been instructed in its use?

Employees signature only

  • Employee signature

  • Employee signature

  • Employee signature

  • Employee signature

  • Employee signature

  • Employee signature

  • Employee signature

  • Employee signature

  • Employee signature

  • Employee signature

  • Employee signature

  • Employee signature

  • Employee signature

  • Employee signature

  • Employee signature

  • Employee signature

  • Employee signaturey

  • Employee signature

  • Employee signature

  • Employee signature

  • Employee signature

Foreman signature only

  • Foreman signature

  • Add signature

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.