DWM Work Site Inspection 1.0

• Site conducted

  Select

• Document No.

• Conducted on

  Date

• Prepared by

• Location
  Address

• Group

  Select Drinking Water Waste Water RM Clayton South River RM Clayton Utoy Creek Hemphill Hemphill Settled Solids Contractor CSOs

  • Drinking Water
  • Waste Water
  • RM Clayton
  • South River
  • RM Clayton
  • Utoy Creek
  • Hemphill
  • Hemphill Settled Solids
  • Contractor
  • CSOs

• Crew Supervisor

Work Site Classification

• Is this a contractor work site?

Personal Protective Equipment

• Are hard hats worn in the workzone?

  Yes

  No

  N/A

• Are appropriate (Class 2 or 3) worn in the workzone?

  Yes

  No

  N/A

• Are steel toe shoes/boots worn?

  Yes

  No

  N/A

• Is appropriate eye protection worn? (safety glasses, face shield ...

  Yes

  No

  N/A

• Is appropriate hearing protection worn?

  Yes

  No

  N/A

• Is the appropriate respirator being used?

  Yes

  No

  N/A

• Is the appropriate hand protection being worn?

  Yes

  No

  N/A

• Is all required PPE present?

  Yes

  No

  N/A

• What's missing?

Excavation/Trenching and Shoring

• Does the work site have an excavation over 4'?

• Complete Excavation Inspection Form!

• Is the excavation safe?

  Safe

  At Risk

  N/A

• Has the audit been completed?

Traffic Control

• Does the site require Traffic Control

• MUTCD
  https://mutcd.fhwa.dot.gov/pdfs/2009r1r2/part6.pdf

• Does the work site have adequate signs present?

  Yes

  No

  N/A

• What signs are needed?

  Select 1500 Yd 1000 Yd 500 Yd Flagger Ahead Merge Left Merge Right One Lane Ahead

  • 1500 Yd
  • 1000 Yd
  • 500 Yd
  • Flagger Ahead
  • Merge Left
  • Merge Right
  • One Lane Ahead

• Are traffic cones placed properly?

  Yes

  No

  N/A

Confined Space

• Is there work being conducted in a confined space?

• Do a confined space audit!

• Is the confined space safe?

  Safe

  At Risk

  N/A

• Audit Completed?

Crystalline Silica

• Crystalline Silica Standard
  https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=1270

• Is crystalline silica being generated at the work site?

• List source of crystalline silica

  Select Cement Asphalt Grout Brick Mortar

  • Cement
  • Asphalt
  • Grout
  • Brick
  • Mortar

• Are the appropriate engineering controls present on tools that are being used to control crystalline silica? (water hoses, vacs)

  Yes

  No

  N/A

• Is the employee using proper PPE to protect from crystalline silica exposure? ( Reference Table 1)

  Yes

  No

  N/A

Hot Work

• Is Hot Work being performed at the work site?

• Complete Hot Work Audit?

• Has the hot work checklist been completed?

Ladders

• Are ladders required for the worksite

• Are the correct ladders being used for the site?

  Yes

  No

  N/A

• Is the ladder correctly placed

  Yes

  No

  N/A

• Is the ladder serviceable (rungs and feet)

  Yes

  No

  N/A

Work Site

• Inactive Work Site/ Crew Not Present ( Document if an IDLH hazard exist and create an action)

• Is the site secure? (Hazards exist to the public) i.e Barriers, Plates

  Safe

  At Risk

  N/A

• Are all utilities properly marked?

  Yes

  No

  N/A

• Are Employees fit for duty/work?

  Yes

  No

  N/A

• Why is the employee not fit for duty?

  Select Medical Condition Possible Alcohol/Drug Intoxication (Refer to management) Erratic Behavior (Refer to management)

  • Medical Condition
  • Possible Alcohol/Drug Intoxication (Refer to management)
  • Erratic Behavior (Refer to management)

• Are all water coolers safe ? (inspect for cleanliness and proper usage)

  Yes

  No

  N/A

• What caused the water cooler to be unsafe?

  Select Cleanliness Contraband Improper Usage

  • Cleanliness
  • Contraband
  • Improper Usage

Summary

• undefined

• Add signature

  Sign

• Did the work site fail for IDLH hazards or was there a work stoppage

  No

  Yes

• Add media

  Media