Information
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State & Local Government (SLG) HSE Program Review
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Project Name
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Program Review Date
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Prepared by
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Location
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Personnel Participating in Program Review
Project Information
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Background
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Project Team
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CH2M HILL Scope
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Add media
Program Implementation
Field Safety Instructions
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FSI in Place
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FSI Available?
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FSI Current?
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FSI Signed?
HSE Training
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Worker Categories Current?
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Worker Category Training?
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Project-Specific Training?
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Site/Project Required Training?
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Vaccinations?
Ergonomic Self-Evaluations
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Worksheet Completed?
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Worksheet Current (at least every 2 years, new workstation or discomfort/pain)?
Water Business Group HSE Budget Policy
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Separate Allocation?
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Separate Task Number?
Subcontractors
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HSE Prequalifed?
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Documentation Complete?
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Certificate of Insurance (COI) on File?
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HSE Training Current?
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AHA in Place, Current & Followed?
HSE Contract
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Contract Tailored?
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Read & Understood by Project Team?
Emergency Preparedness
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Emergencies Identified (General, Fire, Chemical, Severe Weather, etc.)?
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Site-Specific Emergency Response Plan Completed and Documented in FSI?
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Procedures & Contact Information Posted?
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Life Saving Equipment Inspected (fire extinguishers, first aid kits, eye wash and emergency showers)
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Emergency Drills Conducted?
Postings
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Regulatory Information Posted?
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Emergency Contacts Posted?
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Injury Management Posted?
Incidents
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Incident Reporting Procedures Followed?
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Root Causes & Corrective Actions Identified & Implemented?
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CH2M HILL Incident Free?
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Near Misses & Safety Suggestions Reported?
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CH2M HILL Subs Incident Free?
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Third Party Incident Free?
Safety Committee
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Required?
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Safety Committee Charter in Place?
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Comprised Mostly of Non-Management?
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CH2M HILL Participation?
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Meet at Least Monthly?
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Open Forum to Discuss Safety Concern?
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Minutes Taken, Signed & Posted?
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Walks the Project?
Project-Specific Implementation Tools
Self-Assessment Checklists
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Checklists Used According to FSI?
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Findings Corrected?
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Reviewed & Signed by PM?
Chemical Safety
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Inventory Completed?
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SDSs on File?
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Chemical Training Documented?
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WHMIS Training Completed?
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GHS Training Completed?
Confined Space Entry
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CSE Training Completed?
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CSE Entry Certificates Completed?
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Air Monitoring Documented?
Energized Electrical Work
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2015 NFPA 70E Training Completed?
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Energized Electrical Qualified Person Assessment Form Completed?
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Energized Electrical Work Permit Completed?
Fall Protection
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Fall Protection Evaluation Form Completed?
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Fall Protection Training Form Completed?
Safety Planning Tools
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AHA in Place?
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AHA Current & Adequate?
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AHA Followed?
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Daily Pre-Task Safety Plan (DPSP) Completed?
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DPSP Signed by Workers?
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DPSP Updated as Hazards and Tasks Change?
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DPSP Available?
Field Observations
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Animal & Biological
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Atmospheric & Particulate Hazards
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Chemicals
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Confined Space Entry
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Contact/Struck by
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Cranes
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Concrete & Masonry
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Drilling
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Electrical
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Environment
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Equipment & Tools
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Ergonomics
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Excavations
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Fall Protection
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Fire Safety
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Health & Hygiene
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Hearing Conservation
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Heavy Equipment
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Housekeeping
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Illumination
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Ladders & Stairways
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Lock Out / Tag Out (Energy Control)
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Motor Vehicle
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Manual Material Handling (Heavy Lifting)
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Machine Guarding
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Material Storage
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Office Safety
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Personal Protective Equipment
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Personal Safety
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Public Safety
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Respiratory Protection
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Rigging
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Scaffolding
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Security
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Shift Work
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Temperature & Weather
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Traffic Control
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Walking Working Surfaces
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Welding & Cutting
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Work on Water
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Other
Summary
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Summary
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Health & Safety Manager
