“Disclaimer
Although the inspector believes the information contained in this inspection report is correct at the time of inspection, the uncertain and dynamic nature of a job site requires that such inspection always be accompanied with some level of uncertainty as to its accuracy. As such, the inspector(s) and the inspector(s)’ employer and its affiliated entities do not accept responsibility for any consequences arising from the use of the information in this inspection report. The inspection report is based on facts and circumstances observed or that came to the attention of the inspector(s) the day of the inspection and should not be relied upon as an exhaustive record of all possible risks or hazards that may exist or potential improvements that can be made.
Confidentiality Statement
In order to maintain the integrity and credibility of the risk assessment processes and to protect the parties involved, it is understood that the inspector(s) and the inspector(s)’ employer and its affiliated entities will not divulge to unauthorized persons any information obtained during this risk assessment unless legally obligated to do so.”
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Title Page
Audit Title
Client / Site
Conducted on
Prepared by
Location
Personnel
Are lockout tagout procedures in place and in use when required? Is there a lockout tagout kit including locks and tags available for use?
Was a 5x5 conducted and what was it? List the answer below.<br>
Are all work sites adequately illuminated?
Are safety data sheets on site and available to employees?
Is fall protection provided and in use when required?
Are pits, floor openings and holes covered or otherwise guarded?
Are safety gloves (ANSI Cut level 4) used on site and as required while performing work?
Are hard hats or bump caps provided and in use as required? <br>
Are safety glasses and face shields (or goggles) on site and used when necessary?<br>
Are safety vests or high visibility shirts used on site and used when necessary?
Are all work sites clean, sanitary and orderly?
Are walking and working surfaces properly guarded when exposure to fall is present?
Are all extension cords in good condition, properly grounded, equipped with ground plugs, and used for temporary applications?
Are all ladders free from defects, properly labeled, approved and used as intended?
Are all tools and equipment used by employees in good condition?
Are employees aware of the hazards caused by fault or improperly used hand tools?
Is personal protective equipment inspected and in good condition?
Is protection against the affects of occupational noise exposure provided and used?
Any additional comments?
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Anonymous
CSUSA Service Safety Inspection form
“Disclaimer
Although the inspector believes the information contained in this inspection report is correct at the time of inspection, the uncertain and dynamic nature of a job site requires that such inspection always be accompanied with some level of uncertainty as to its accuracy. As such, the inspector(s) and the inspector(s)’ employer and its affiliated entities do not accept responsibility for any consequences arising from the use of the information in this inspection report. The inspection report is based on facts and circumstances observed or that came to the attention of the inspector(s) the day of the inspection and should not be relied upon as an exhaustive record of all possible risks or hazards that may exist or potential improvements that can be made.
Confidentiality Statement
In order to maintain the integrity and credibility of the risk assessment processes and to protect the parties involved, it is understood that the inspector(s) and the inspector(s)’ employer and its affiliated entities will not divulge to unauthorized persons any information obtained during this risk assessment unless legally obligated to do so.”
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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.
