Title Page

  • Safety Inspection

  • Conducted on

  • Conducted by

  • Location

  • Supervisor

  • Competent Person

  • Weather

1.0 Workplace

  • 1.1-Code 753 (Mark Outs)

  • 1.2-Competent Person

  • 1.3-Fire extinguisher visible, current, & immediately available

  • 1.4-First Aid Kit/Blood Bourne Pathogen Kit on-site & current

  • 1.5-Burn Gel & Burn Blanket current

  • 1.6-Spill Kit on-site

  • 1.7-Air monitor in use, calibrated, & current

2.0 Administrative

  • 2.1-Documentation of Job Briefing

  • 2.2-HASP on-site & current

  • 2.3-Current permits posted & visible

  • 2.4-Complete Job Package on-site

  • 2.5-Current RWLB matrix posted

3.0 Work Area Protection

  • 3.1-Flagger present

  • 3.2-Barricades/Cones/Stanchions complete & in compliance

  • 3.3-MUTCD signs in use where required

  • 3.4-Spotter present & escorting heavy equipment when necessary

  • 3.5-Pedestrians provided with a safe & clear path of travel

  • 3.6-Road/sidewalk plates in compliance

  • 3.7-Slings/chains in good condition

  • 3.8-Rubber Electrical Gloves (KV) dated with expiration date

  • 3.9-Proper PPE in use when required

  • 3.10-Vehicle's engine turned off (Idling regulations)

  • 3.11-Wheels chocked when truck on standby (driver not in cab)

  • 3.12-All tools in good condition

  • 3.13-Adequate set-up

  • 3.14-Housekeeping in place on-site & in trucks to prevent slips, trips, and falls

4.0 Excavation

  • 4.1-Spoils & equipment 2' away from excavation

  • 4.2-Gas monitoring where required

  • 4.3-Ladders used at 4' depth or greater & extending 3' above landing

  • 4.4-Ladders in place every 25' of lateral travel

  • 4.5-Shoring/sheeting at 5' or greater or when required

  • 4.6-Daily excavation inspection conducted

5.0 Gas/Fusion Equipment

  • 3.1-Contact Pyrometer

  • 3.2-Manual Fusion machine

  • 3.3-Facer

  • 3.4 Heating Iron

  • 3.5 Hydraulic Fusion Machine

  • 3.6-Electrofusion Machine

  • 3.7-Airline Respirator complete including inhalation valve, exhalation valve, hose assembly, speaking diaphragm, gaskets, connections, regulator, alarm, and hoses

  • 3.8-Harness & Line

  • 3.9-Escape Kit current (Masks & O2)

  • 3.10-GMI Current

Sign off

  • Auditor's signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. 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.