Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
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Project Name:
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Work Team/Contractor:
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Fill in the the corresponding item using one of the following notations; use "Yes" to denote observed items that are in compliance. Use "No" to indicate when an observed condition is not compliant. Use "NA" for items that do not apply. Use notes below each section to further explain discrepancies.
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Job Safety Analysis or other Hazard Assessment completed
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General / Hot Work Permits
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Contractor Work
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Contractor employees have current On Boarding Training?
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PPE
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Basic
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Specialized
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Walking & Working Surfaces
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Slip, Trip & Fall Hazards
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Guarding / Barricades
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Adequate Work Surfaces
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Tools & Equipment
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Guarding
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T&E Inspected
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T&E Maintained
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Electrical Safety
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GFI circuits
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Power Cords
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Temp. panels
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Hygiene
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Exposure (chemical / environmental)
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Restrooms
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Signs & Barricades
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Present & Maintained
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Proper for task
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Traffic Control
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Trained personnel
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Proper for task
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Working At Heights
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Proper Fall Arrest Equipment
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100% & Adequate tie-off
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Hot Work
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Combustibles Removed 35'
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Signage Posted
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Fire Extinguisher
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Excavation
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Utilities Identified
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Daily Inspection
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4, 5, 6 Followed
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Spoil Pile 2' From Edge
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Material Handling
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Manual
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Mechanical
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Transporting
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Housekeeping
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Equipment Storage
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Material Storage
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Wastes Managed
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Confined Space
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Permitted
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Rescue Plan
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Adequate personnel
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Pressure Testing
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Distance maintained
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Lock-out / Tag-out
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System in place
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Proper for application
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Emergency Response
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Response Determined
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Adequate response equipment
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Radiation Sources
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Properly shielded
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Signs & Barricades
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Fire Protection / Prevention
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Flam. / Comb. Material Storage
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Smoking
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Fuel storage
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Other
