Title Page
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Conducted on
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Inspection by
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Project name
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Project number
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Person in charge
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Location of project
Project Information
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Describe the work activity
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How many crew members are on site
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How many company vehicles and equipment are on site
1. Job Hazard Analysis
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JSA available and enforced at the work site
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JSA presented in a timely manner
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Does JSA include all tasks being performed
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High-risk hazards recorded on the JSA
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Required information properly filled in on the JSA
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Person in charge has signed the JSA
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Employees and visitors briefed of hazards and signed in
2. First Aid & Medical / Emergency Preparedness
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First aid kit, blood bourne pathogen kit, and eye wash bottle
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Supply expiration dates checked
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AED on-site, inspected, and documented on JSA
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Emergency action plan available
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All personnel briefed on the site emergency exit routes
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Fire extinguisher condition and inspections checked
3. Housekeeping
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Clear ingress / egress to the site
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Good housekeeping is practiced in all locations
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Trash contained and removed from site properly
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Sanitary facilities clean and secured
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Vehicles are clean and organized
4. Electrical
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Extension cords clear from pathways or guarded
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GFCI’s installed and maintained
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Cords in good condition
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Proper use of temporary power
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Proper grounding in place
5. Storm water pollution prevention (SWPP)
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Environmental training for workers
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BMP’s installed and maintained
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Adequate spill kits available
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Nuisance dust controled
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Hazardous material stored properly
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Adequate secondary containment or wash out location
6. Rigging and slinging
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Rigging and slings inspected and tags present
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Rigging stored properly
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Lift plan available as needed
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Proper use of rigging observed
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Tag lines identified and inspected
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Workers aware of proper Inspection methods
7. Signs and barricades
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Appropriate signs to warn against hazards
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Traffic control plan established and utilized correctly
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Barricades installed and appropriate for the hazard
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Overhead lines identified and clearance verified
Personal protective equipment
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All personnel wearing hard hat while working
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All personnel wearing gloves while working
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All personnel wearing safety glasses / side shields
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All personnel wearing safety toe footwear while working
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All personnel wearing high visibility gear class 2 / 3
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Hearing protection sufficient for the tasks
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Face shields available and utilized
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Crew leader ensuring crew uses proper PPE
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Is PPE in good condition
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H2S monitor available / stored properly
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Dust masks / respirators available
9. Fall protection
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Workers are able to demonstrate a proper inspection
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Workers maintain proper storage of fall protection gear
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Fall protection utilized in appropriate situations
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Fall protection used has compatible connections
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Workers attach to proper anchor points
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Fall protection labels are legible
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Fall protection documented in the pre-job briefing
10. Trenching, excavations, and barricades
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Competent person present
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Sloped, benched, or shored per soil conditions
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Daily inspections complete
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Perimeter trench protection / barricade in place
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Proper clearance of soils from edge
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Ingress / egress of trench adequate
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Proper ladder use, clearance, and condition
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Site hazards marked (811 notified and utilities verified)
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Public is protected from hazards
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Employees are aware and trained on hazard mitigation
11. Equipment and vehicles
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Review of equipment inspection reports
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Equipment swing radius barricaded as needed
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Equipment / lines properly grounded
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Proper use of seat belt
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Operated in a safe manner
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Operator properly trained / competent
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Spotters identified and utilized
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Training docs available
12. Hand and power tools
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Tools in good condition and stored properly
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Personnel properly trained
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Proper tool utilized for the job
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Guards / attachments in place and functional
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Tools and storage areas near and organized