Title Page

  • Job Number:

  • Location
  • Project Manager:

  • Foreman:

  • Conducted on

  • Type of Structure:

  • Prepared by

PART 1: JOB SITE DOCUMENTATION

  • A. Do all employees have Patriot ID Badges?

  • B. Was a Job Safety Analysis conducted, form filled out and on site?

  • C. Was the Daily Job Safety Analysis form filled out and on site?

  • D. Are the applicable safety signs posted?

  • E. Is there a competent person on site?

  • F. Is someone on site certified in First Aid/CPR/BBP?

  • G. Has the emergency data form been filled out and posted?

  • H. Is there a documented site-specific direction for emergency rescue on site?

  • I. If employees are exposed to a fall, is a documented rescue plan and equipment on site?

  • J. Are MSDS's available for the material being used on site?

  • K. Is there a documented procedure for any overhead electrical hazards?

PART 2: JOB SITE CONDITIONS (INCLUDE ENVIRONMENTALS)

  • A. Is the work site clean of trash?

  • B. Are materials stored properly and orderly?

  • C. Are measures taken to prevent access by unauthorized personnel to the site?

  • D. Are areas barricaded as required?

  • E. Is drinking water available?

  • F. Are chemical, flammable and combustible liquids stored properly? (i.e., no plastic gas cans)

  • G. Are fire extinguishers of the appropriate size and type available, and with current inspection tags?

  • H. Are plant and animal hazards addressed and documented?

PART 3: PPE

  • A. Are employees wearing hard hats?

  • B. Are employees wearing proper work boots?

  • C. Are safety glasses being used? (if applicable)

  • D. Are employees wearing gloves? (if applicable)

  • E. Are employees dressed in appropriate work clothing?

  • F. Is hearing protection being used/or available? (if applicable)

PART 4: FALL PROTECTION EQUIPMENT and USE

  • A. Do employees that are exposed to falls, have documented training?

  • B. Is fall protection equipment being inspected daily and documented?

  • C. Is fall protection equipment in working condition?

  • D. If employees are using fall protection, are they attached 100%?

  • E. Is the proper equipment on the site to complete the task?

PART 5: RF

  • A . Have RF hazards been considered (if applicable)?

  • B. Is there a procedure in place to account for RF exposure if there is a possibility of overexposure (if applicable)

  • C. Are RF Monitors on site?

PART 6: ELECTRICAL (INCLUDE OVERHEAD)

  • A. Are employees familiar with Lock Out/ Tag Out procedures?

  • B. Is the tower grounded during construction? (If applicable)

  • C. Are electrical panels covered when not being worked on?

  • D. Are (GFCI’S) in use (If Applicable)?

  • E. Are extension cords in good condition?

  • F. Has the Power Company been notified? (If applicable)

  • G. Is GFCI on the generator operational?

PART 7: CRANES

  • A. Are boom trucks or cranes properly cribbed?

  • B. Is annual inspection tag current or inspection report available?

  • C. Is crane operator qualified and carrying an operator’s certificate?

  • D. Are load charts posted and readily available to crane operator?

  • E. Is headache ball properly marked?

  • F. Is end connection properly secured?

  • G. Are daily inspections being conducted and documented?

  • H. Are two-way radios being tested daily, if being used?

  • I. Is a hand signal chart posted and visible to all personnel on site?

  • J. Has personnel lifting plan been filled out and on site? (If applicable)

PART 8: ROOFTOP SAFETY

  • A. Roof’s Edge: is there a handrail or a parapet of sufficient height ? (42+/- 3”)

  • B. Is Warning line system set up 15ft from the edge?

  • C. Is the roof hatch / penthouse door closed/ unauthorized access

  • D. Are Skylights protected

  • E. Are Employees exposed to falls protected with PFAS or Restraint System?

  • F. Sufficient Anchor points for Arrest (5000lbs) or Restraint (1000lbs) selected?

  • G. Anchor Points separate for each individual rope? No 2 ropes to same anchor?

  • H. Is Controlled Descent (CD) used to access work location?

  • I. Is the CD device equipped with auto stop function i.e Petzl ID?

  • J. Is Secondary Lifeline (LL) being used with 3ft shock absorbing lanyard?

  • K. Is a separate Lifeline being used for each CD individual? No common LL?

  • L. Does each LL reach the ground? If NOT is there a knot at the end?

  • M. Are two-way radios being tested daily, (if being used)?

PART 9: PERSONNEL LIFTING

  • A. Is the hoist approved for lifting personnel?

  • B. Has a pre-lift meeting been held, documented and made available on site?

  • C. In the pre-lift plan, was the trial lift completed and documented?

  • D. If a personnel platform is on site, does it have an identification plate with the proper data in place?

  • E. If a gin pole is being used, does it have a load chart?

PART 10: CAPSTAN HOIST

  • A. Is hoist mounted properly and securely on sufficient anchorage?

  • B. Are operator controls in good working condition? (Foot Pedal or Switch)

  • C. Is rope of sufficient size, strength, and type for load being lifted?

  • D. Is S.W.L. visible on the cathead?

  • E. Is the manufacturer’s labeling indicating load rating legible?

  • F. Is the capstan head free of grooves?

PART 11: RIGGING & BLOCKS

  • A. Are proper rigging practices being utilized?

  • B. Are the tags on synthetic slings legible?

  • C. Are synthetic slings in good condition?

  • D. Is rigging equipment being inspected daily and the inspection documented?

  • E. Are the safeties on all hooks in good condition?

  • F. Are tag lines in working condition?

PART 12: TRENCHING & EXCAVATION

  • A. Are open holes properly guarded?

  • B. If employees are in the trench is it properly sloped and/or benched?

  • C. Is the proper equipment on site to perform the work?

  • D. If employees are in the trench is there proper entry and egress?

PART 13: HEAVY EQUIPMENT

  • A. Is back-up alarm working properly?

  • B. Is RollOver Protection installed and in good condition?

  • C. Are Hazard Lights working properly?

  • D. Are buckets and booms free of cracks and defects?

  • E. Are personnel clear of the danger area or working radius?

PART 14: HAND/POWER TOOLS

  • A. Are electrical tools in good condition?

  • B. Are the cords in good condition

  • C. Are they properly grounded or double insulated?

  • D. Are proper guards in place?

PART 15: LADDERS

  • A. Are units well maintained and in good working order?

  • B. Are ladders at the proper slope? (4:1 ratio)

  • C. Does the ladder extend 36 inches past the landing?

  • D. Is the ladder stable, on good ground?

PART 16: VEHICLES

  • A. Is vehicle interior clean?

  • B. Is vehicle exterior clean (if conditions are suitable)?

  • C. Does the vehicle have a fire extinguisher with a rating of 5ABC?

  • D. Is the fire extinguisher location identified?

  • E. Is a well-stocked first-aid kit located in the vehicle?

  • F. Is the first aid location marked and identified?

  • G. Is PTS-5 Vehicle Accident Form in the glove box in case of an accident?

  • H. Has a monthly inspection report been completed for the vehicle?

PART 18: SYNTHETIC ROPES

  • A. Are all ropes labeled properly and is the label visible?

  • B. Is the load rope in good condition?

  • C. Is the tag rope in good condition?

  • D. Is the vertical fall protection rope in good condition?

  • E. Is the descent control rope in good condition?

  • F. Is the rescue rope in good condition?

PART 19: OVERALL IMPRESSION OF THE SITE VISIT

Crew Members

REPORT REVIEW

  • This Report Was Reviewed With:

SIGNATURES:

  • Site Supervisor Signature:

  • Auditor Signature:

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