DLZ Industrial

• Project/Job Number #

• Project/Job

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Permits/JSA

• Permit reviewed and signed off from owner?

  Safe

  At Risk

  N/A

• JSA reviewed with crews and signed off?

  Safe

  At Risk

  N/A

• Hazard Recognition reporting

  Safe

  At Risk

  N/A

• Near Miss reporting

  Safe

  At Risk

  N/A

• Other

  Safe

  At Risk

  N/A

Work Areas

• General Housekeeping

  Safe

  At Risk

  N/A

• Walking - Working Surfaces

  Safe

  At Risk

  N/A

• Unprotected Sides or Holes

  Safe

  At Risk

  N/A

• Roadways - Barricades and Signs in Place

  Safe

  At Risk

  N/A

• Water - Garbage Cans available

  Safe

  At Risk

  N/A

• Sanitary Facilities

  Safe

  At Risk

  N/A

• Impalement Hazards

  Safe

  At Risk

  N/A

• Other Crafts in Area ( SIM OPs)

  Safe

  At Risk

  N/A

• Other

  Safe

  At Risk

  N/A

First Aid/Emergency

• First Aid Kit

  Safe

  At Risk

  N/A

• Eye Wash Facilities in Field

  Safe

  At Risk

  N/A

• Access to Eye Wash

  Safe

  At Risk

  N/A

• Evacuation and Assembly Points

  Safe

  At Risk

  N/A

• Emergency Contacts / Numbers

  Safe

  At Risk

  N/A

PPE

• Face Shield / Goggles (If Required)

  Safe

  At Risk

  N/A

• Hard Hats

  Safe

  At Risk

  N/A

• Hearing Protection

  Safe

  At Risk

  N/A

• Clothing ( FRC, Greens) In good condition

  Safe

  At Risk

  N/A

• Gloves

  Safe

  At Risk

  N/A

• Foot Protection

  Safe

  At Risk

  N/A

• Safety Glasses with Side Shields

  Safe

  At Risk

  N/A

• Respiratory Protection (If Required)

  Safe

  At Risk

  N/A

• Other

  Safe

  At Risk

  N/A

Fall Protection

• Stored Properly

  Safe

  At Risk

  N/A

• Emergency Rescue Plan

  Safe

  At Risk

  N/A

• Trained Personnel

  Safe

  At Risk

  N/A

• Proper Fit

  Safe

  At Risk

  N/A

• Suitable Anchor Point

  Safe

  At Risk

  N/A

• Inspected/Color Coded

  Safe

  At Risk

  N/A

• Other

  Safe

  At Risk

  N/A

Confined Space Entry

• Trained Personnel (Entrant)

  Safe

  At Risk

  N/A

• Attendant Present (Trained)

  Safe

  At Risk

  N/A

• Permit in Place

  Safe

  At Risk

  N/A

• Sign in Sheet (Entry)

  Safe

  At Risk

  N/A

• Air Monitoring

  Safe

  At Risk

  N/A

• Emergency Rescue Plan

  Safe

  At Risk

  N/A

• Permit Followed

  Safe

  At Risk

  N/A

Excavations

• Trained Personnal

  Safe

  At Risk

  N/A

• Access/Egress

  Safe

  At Risk

  N/A

• Soil Condition

  Safe

  At Risk

  N/A

• Shoring/Shielding/Slpoing

  Safe

  At Risk

  N/A

• Barricades

  Safe

  At Risk

  N/A

• Spoil Pile (At Least 3ft from edge)

  Safe

  At Risk

  N/A

• Air Monitoring

  Safe

  At Risk

  N/A

• Emergency Rescue Plan

  Safe

  At Risk

  N/A

Scaffold / Ladders

• Trained Personnel (User)

  Safe

  At Risk

  N/A

• Condition (Visual - hand rails, toe boards, mid-rails, Level ground)

  Safe

  At Risk

  N/A

• Access / Egress

  Safe

  At Risk

  N/A

• Inspection / Tagged Correctly

  Safe

  At Risk

  N/A

• Away From Powerlines

  Safe

  At Risk

  N/A

• Base/Footing/Set Up

  Safe

  At Risk

  N/A

• Inspection/Color Coded

  Safe

  At Risk

  N/A

• Proper Ladder for Job

  Safe

  At Risk

  N/A

Tools and Equipment

• In Good Condition

  Safe

  At Risk

  N/A

• Inspected / Color Coded

  Safe

  At Risk

  N/A

• Other

  Safe

  At Risk

  N/A

Electrical

• GFCI in Place

  Safe

  At Risk

  N/A

• Extension Cords (Inspected,good condition)

  Safe

  At Risk

  N/A

• Power Tools

  Safe

  At Risk

  N/A

HAZCOM

• MSDS

  Safe

  At Risk

  N/A

• MSDS for Chemicals on Site

  Safe

  At Risk

  N/A

• Training - Right to Know(GHS)

  Safe

  At Risk

  N/A

Comments/Recommendations

Sign Off

• Safety Representative

  Sign

• Project Manager

  Sign

• Crew Personnel

  Sign