Information
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Document No.
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
Work Area Preparation
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Lockout/Tagout procedures correct
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Confined Space Entry: permits posted, etc.
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Hot Work Permit: Permit posted, etc.
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Spills and Slippery Surfaces: Identified and corrected
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Tripping Hazards: Identified and corrected
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Housekeeping: Area picked up and clean for safe work
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Guards and Barriers: In place and working
PPE
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Head Protective: Hard hats in use with overhead work
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Eye and Face Protection: safety glasses and faceshield
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Hearing Protection: In required areas
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Hand Protection: Moving material, using knives etc.
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Arm Protection: When using knives, chemical use etc.
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Foot Protection: Wearing required steel toed shoes
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Body Protection: When working w/ acids, chemicals etc
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Respiratory Protection: When required
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Fall Protection: When falls of 6' or greater, ladder use
Body Mechanics and Ergonomics
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Lifting/Carrying/Pulling/Pushing: Body movement
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Line of Fire: Body location, regarding machine ops.
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Pinch Point: Body location between objects.
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Path of Travel: Body location between equipment
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Path of Travel: Climbing from one elevation to next
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Path of Travel: Flat surface
Tools and Equipment
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Selection: Proper tool or equipment for job
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Condition: Tools & equipment in safe conditions for use
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Use: Tools & equipment being used as intended
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Mobile Equipment: Inspected prier to use, safe ops.
Follow Up
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Is any follow up required?
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Commendable behaviors observed:
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