Information

  • Date and Time

  • Company

  • Job Name

  • Job Number

  • Location
  • Leader

  • Weather

  • Inspector

General Requirements

  • Potable Water, Toilet and Hand washing Facilities

  • First Aid Kit

  • Fire Extinguishers (minimum 2)

  • SDS Collection and Electronic Pad

  • Emergency Phone Number Poster

  • Fall Plan and JHA signed

  • Mentoring Program

  • OSHA 3165 Poster

Personal Protection

  • Safety Glasses

  • Hard Hats

  • Hearing Protection

  • Respirators

  • Face Shields/Goggles

  • Protective Clothing

  • Safety Shoes

  • Gloves

  • Safety Harness & Lanyard

Roof Access

  • Ladder

  • Stairs

  • Elevator

  • Stair Tower

  • Roof Hatch

Fall Protection

  • Motion Stopping System (MSS)

  • Guard Rail System

  • Personal Fall Arrest System

  • Parapet Walls (minimum 39")

  • Restraint System (zero exposure)

  • Warning Lines (between 34"-39")

  • Safety Monitor (see Fall Plan)

Material Handling

  • Hoist/Crane Inspected

  • MSS in Place

  • Proper Counterweights and Secured

Electrical

  • Ground Fault Circuit Interupter

  • Battery Powered

  • Cord Sets in Compliance

  • Tools in Compliance

  • Generator Use/Grounding

  • Guards Installed on Tools

  • Power Lines Minimum of 10' from Walking/Working Area

  • Power Line Owner Notified Prior to Work

  • Insulated/Blanketed Power Lines

Covers Over Openings

  • Capable of Withstanding Twice the Load

  • Secured From Movement

  • Marked "Cover-Do Not Remove"

Trash Chute Area

  • Trash Chute Properly Secured

  • Dumpsters Not Overloaded

  • MSS in Place

  • Chute Area Neat and Orderly

Housekeeping and Material Storage

  • Roof Area Neat and Orderly

  • Flammable Storage Separated and Posted

  • Fire Extinguisher within 10'-25' of Flammable Storage

  • Fire Extinguisher Within 75' of Work Area

  • Materials Properly Stored and Secured to Prevent Tipping

  • Materials Stored Over Column Lines and Beams

  • Dumpster Not Overloaded

  • Dumpster Area Properly Barricaded

Power Industrial Trucks

  • Proof of Certification on Operator

  • Seat Belt Worn

  • Back Up Alarm and Horn Operable

  • Manufacturer's Rating Visible and Legible/Load Chart

  • Inspection Documented Prior to Use

Aerial Lifts

  • Inspection Documented Prior to Use

  • Outriggers Used (when applicable)

  • Properly Barricaded (where applicable)

  • PFAS Used

Scaffolding

  • Scaffold Inspected Daily Before Use and Documented

  • Level/Plumb/Fall Protection in Place

  • Proper Securement of Scaffolding and Feet

Punch Cards

  • Kettle Inspected and Documented

  • Mobile Fall Protection Inspected and Documented

Comments and Observations

  • Comments

  • MEDIA

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.