Diversified Communications Services

• Diversified Site Safety AUdit

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by- John Rudy

• Location
  Address

• Personnel

• Customer:

• Type of structure:

  Select Monopole Self-Supporter Guyed Rooftop Water Tank Other

  • Monopole
  • Self-Supporter
  • Guyed
  • Rooftop
  • Water Tank
  • Other

• Scope of work:

Part 1: Job Site Documentation

• Was a Job Hazard Analysis conducted, form filled out and on site?

  Yes

  No

  N/A

• Are applicable safety banner/signs posted?

  Yes

  No

  N/A

• Is there a competent person on site?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Has the emergency data and action plan form been filled out and posted?

  Yes

  No

  N/A

• Has a site-specific emergency rescue plan been developed and documented?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Part 2: Job Site Conditions (Include Enviromentals)

• Is the work site clean of trash?

  Safe

  At Risk

  N/A

• Are materials stored properly and orderly?

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

• Are areas barricaded as required?

  Safe

  At Risk

  N/A

• Is drinking water available?

  Yes

  No

  N/A

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

  Safe

  At Risk

  N/A

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

  Yes

  No

  N/A

• Are plant and animal hazards addressed and documented?

  Yes

  No

  N/A

Part 3: PPE

• Are employees wearing hard hats?

  Yes

  No

  N/A

• Are employees wearing proper work boots?

  Yes

  No

  N/A

• Are safety glasses being used?

  Safe

  At Risk

  N/A

• Are employees wearing work gloves?

  Safe

  At Risk

  N/A

• Are employees dressed in appropriate work clothing?

  Safe

  At Risk

  N/A

• Is hearing protection being used?

  Safe

  At Risk

  N/A

Part 4: Fall Protection Equipment

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

  Yes

  No

  N/A

• Is fall protection equipment being inspected daily and documented?

  Yes

  No

  N/A

• Are fall protection tags legible?

  Yes

  No

  N/A

• If work being preformed requires fall protection, is it being used 100%?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Part 5: RF

• Are RF monitors being worn by all climbers?

  Yes

  No

  N/A

• Are RF monitors inside calibration dates?

  Yes

  No

  N/A

• Is there a procedure in place to reduce the RF exposure within statutory limits?

  Safe

  At Risk

  N/A

Part 6: Electrical (Include Overhead)

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

  Yes

  No

  N/A

• Is the tower grounded during construction?

  Safe

  At Risk

  N/A

• Are electrical panels covered with not being worked on?

  Safe

  At Risk

  N/A

• Are Ground Fault Circuit Interrupters (GFCI) available?

  Yes

  No

  N/A

• Are extension cords in good condition? ( i.e., No splices, cuts, exposed wires)

  Yes

  No

  N/A

• Has the power company been notified?

  Yes

  No

  N/A

• Is GFCI on the generator operational?

  Safe

  At Risk

  N/A

Part 10: Catheads

• Is cathead mounted properly and securely?

  Safe

  At Risk

  N/A

• Is rope hook installed properly?

  Yes

  No

  N/A

• Is rope lock being used?

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

• Is S.W.L. visible on the cathead?

  Yes

  No

  N/A

• Is the manufacturer's labeling indicated load rating legible?

  Yes

  No

  N/A

• Is there sufficient anchorage for the load rating of the unit?

  Safe

  At Risk

  N/A

• Is the capstan free of grooves?

  Yes

  No

  N/A

Part 11: Rigging and Blocks

• Are proper rigging practices being utilized?

  Safe

  At Risk

  N/A

• Is rigging equipment in good condition?

  Safe

  At Risk

  N/A

• Are the tags on synthetic slings legible?

  Yes

  No

  N/A

• Is rigging equipment being inspected daily and the inspection document?

  Yes

  No

  N/A

• Are tag lines in good condition?

  Safe

  At Risk

  N/A

Part 13: Trenching & Excavating

• Are open holes properly guarded?

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

Part 14: Heavy Equipment

• Is back-up alarm working properly?

  Yes

  No

  N/A

• Is Roll Over Protection installed and in good condition?

  Safe

  At Risk

  N/A

• Are Safety Interlocks operational? (If applicable)

  Safe

  At Risk

  N/A

• Are Hazard Lights working properly?

  Yes

  No

  N/A

• Are buckets and booms free of cracks and defects?

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

Part 15: Hand/Power Tools

• Are electrical tools in good condition?

  Safe

  At Risk

  N/A

• Are they properly grounded or double insulated?

  Safe

  At Risk

  N/A

• Are proper guards in place?

  Safe

  At Risk

  N/A

Part 16: Ladders

• Are ladders rated 1A or greater?

  Yes

  No

  N/A

• Are units well-maintained and in good working order?

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

• Does the ladder extend 36 inches past the landing?

  Safe

  At Risk

  N/A

• Is the ladder stable, on good ground?

  Safe

  At Risk

  N/A

• Is the ladder set up correctly?

  Safe

  At Risk

  N/A

Part 17: Vehicles

• Is vehicle interior clean?

  Yes

  No

  N/A

• Is vehicle exterior clean?

  Yes

  No

  N/A

• Is the interior or exterior free of damage?

  Yes

  No

  N/A

• Is the windshield in good condition?

  Yes

  No

  N/A

• Are tires in good condition?

  Safe

  At Risk

  N/A

• Is there documentation stating last and next oil change date and mileage?

  Yes

  No

  N/A

• Date:

  Date

• Mileage:

• Does the vehicle have a fire extinguisher with a rating of 10ABC and equipped with a current monthly inspection tag?

  Yes

  No

  N/A

• Is the fire extinguisher location identified?

  Yes

  No

  N/A

• Is a well-stocked first-aid kit complete with CPR airway located in the vehicle?

  Yes

  No

  N/A

• Is the vehicle safety book in the vehicle?

  Yes

  No

  N/A

• Are all inspection stickers current?

  Yes

  No

  N/A

• Is the insurance and registration certificate current and readily available?

  Yes

  No

  N/A

• If your company uses a driver's accident report form, is it in the glove box in case of an accident?

  Yes

  No

  N/A

• Is there a monthly/daily inspection report?

  Yes

  No

  N/A

Part 18: DOT Drivers and Vehicles

• Is CDL valid for equipment being used?

  Yes

  No

  N/A

• Do drivers have CDL/DOT medical cards?

  Yes

  No

  N/A

• Is Drivers Daily Log (hours of service) current? (If applicable)

  Yes

  No

  N/A

• Are Daily Vehicle Inspection Reports (DVIR) current?

  Yes

  No

  N/A

• Is vehicle properly labeled on each side?

  Yes

  No

  N/A

• Are emergency reflectors in the vehicle?

  Yes

  No

  N/A

Overall:

• Comments:

• Result:

  Outstanding

  Above Average

  Average

  Below Average

• Amount of time spent on site:

  Date

• Necessary to follow up with written documentation?

  Yes

  No

  N/A

• If any deficiencies, we're they corrected immediately?

  Yes

  No

  N/A

• Report was reviewed with:

  Supervisor

  Crew

Supervisor:

• Supervisor:

  Sign

Auditor:

• Auditor: John Rudy

  Sign