Title Page
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Client
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Contractor
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Conducted on
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Prepared by
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Location
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Contractors Onsite (Name and Count)
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Personnel Count (Total Onsite)
General Work Activities
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If observed check box (If not checked then it is N/A)
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Supervisor present during activities
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Workers trained for task
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JHA in place and reviewed with crew <br>
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Worker(s) with proper PPE for activities
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Plan to protect workers from recognized hazards
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Worker trained for proper equipment use
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Fall protection plan <br>
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Qualified Equipment Operators
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Workers using fall protection as needed
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No unauthorized modifications of equipment
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Equipment in use inspected, maintained, and used as required
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No visible damage to equipment
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Permit issued and posted in immediate work area as needed
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Work area cleared and unobstructed
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Trip/slip hazards controlled
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Proper use of equipment as intended
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Clearance from surrounding hazards maintained
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Environmental hazards identified and controlled
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Tool guards and safety features provided and maintained on all tools
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Fire prevention and suppression provided
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Adequate lighting provided for task
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Construction waste properly controlled and disposed of
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Measures provided to protect others in work area
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Work area properly secured from unauthorized access
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Proper containers for storage and handling of materials
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Traffic Control devices
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Public Fairways
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Issues not currently identified in this section
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Summary of Issues if needed
Confined Space
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If observed check box (If not checked then it is N/A)
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Workers trained for task
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JHA in place and reviewed with crew <br>
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Supervisor present during activities
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Qualified equipment operators
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Worker(s) with proper PPE for activities
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Fall protection plan <br>
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Workers using fall protection as required
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Equipment in use inspected, maintained, and used as required
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Type of confined space determined <br>
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Permit space plan developed and communicated
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Permit issued as needed
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Air quality tested and continuously monitored
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Alarms and warning devices functioning properly
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All present hazards isolated or controlled
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Illumination or work area provided
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Ventilation provided
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Warning/information and signage posted
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Stand by worker trained and equipped for task
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Entry worker(s) trained and equipped for task
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Respiratory protection provided as needed
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Portable equipment grounded and insulated as required
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Work area controlled for access
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Access/egress provided
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Clearance from surrounding hazards manitained
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Emergency plan provided
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Emergency equipment provided
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Means of communication provided
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Issues not currently identified in this section
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Summary of Issues if needed
Cranes and Hoisting Equipment
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If observed check box (If not checked then it is N/A)
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Supervisor present during activities
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Workers trained for task
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JHA in place and reviewed with crew <br>
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Qualified Equipment Operators
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Fall protection plan <br>
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Workers using fall protection as required
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Equipment in use, inspected, maintained, and used as required.
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Worker(s) with proper PPE for activities
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No visible damage to equipment
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Annual inspection completed and documented
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Daily inspections completed and documented
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Labels and load chart in place and legible
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Safety features of equipment operational and in use
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Operator Manual provided
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Alarms and Warning Devices functioning
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No unapproved modifications of equipment
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Additional ground support pads provided as required
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Ground level, stable, unobstructed and able to support load
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Anti Two block device provided and operational
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Pathway of travel level, stable, unobstructed, and able to support intended load
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Tag lines used on all lifts
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Area below lift secured or overhead protection provided
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Clearance of surronding hazards maintained
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Swing Radius Barricaded
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Means of overhead lift warning provided
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Qualified Riggers identified and documented
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Rigging Equipment inspected, tagged, maintained, and used properly
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Base of tower crane secured from unauthorized access
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Emergency shut down provided
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Material layout and lift sequence controlled
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Multiple (christmas tree) lifts are not being performed
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Critical lift plan developed and communicated as needed
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Summary of Issues if needed
Electrical
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If observed check box (If not checked then it is N/A)
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Supervisor present during activities
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Workers trained for task
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JHA in place and reviewed with crew <br>
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Fall protection plan <br>
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Workers using fall protection as needed
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Workers trained for proper equipment use
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Worker(s) with proper PPE for activities
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Qualified equipment operators provided as needed
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Labels in place and legible
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No unauthorized modifications of equipment
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Equipment in use, inspected, maintained, and used as required.
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No visible damage to equipment
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Permits issued and posted in the immediate work area as needed
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Work area clear and unobstructed
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Proper use of equipment as intended
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Clearance from surrounding hazards maintained
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Trip/slip hazards controlled
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Electrical cord condition. Proper size for load?
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Temporary panels installed and maintained.
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Energized panels labeled, secured and controlled.
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No storage in or around panels
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Fire prevention and suppression provided
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GFCI in use as required
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Proper grounding of equipment
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Lightening protection provided as required
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High Voltage proximity plan
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Lockout / Tagout procedures provided
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Temporary lights installed and maintained
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Engergized switches, receptacles, and outlets covered
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Enclosures secured from unauthorized access
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Portable tools grounded and insulated
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Issues not currently identified in this section
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Summary of Issues if needed
Excavation
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If observed check box (If not checked then it is N/A)
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Supervisor present during activities
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Competent person identified and documented
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Competent person conducts duties as required
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Workers trained for task
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JHA in place and reviewed with crew <br>
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Competent person present during activies
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Worker(s) with proper PPE for activities
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Fall protection plan <br>
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Workers using fall protection as needed
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Equipment in use, inspected, maintained, and used as required.
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Qualified equipment operators provided as needed
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Trench plan developed and communicated
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Soil classification determined
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Surface encumbrances removed or supported
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Permits issued as needed
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Excavation support system (shoring/benching) provided
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Spoils, materials, equipment located appropriate distance from excavation
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All present hazards isolated or controlled
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Barriers provided and maintained around open sides
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Walkway, bridging, or plates provided as needed
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Soft barricades offset minimum 6 feet
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Overhead protection provided for workers in excavation
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Plan in place when location of underground installations not known
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Underground installations protected, supported, or removed
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Utilities/underground installations located prior to excavating
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Clearance from surrounding hazards maintained
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Proper access/egress provided
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Accumulation of water controlled
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Emergency equipment provided
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Air quality tested/monitored as needed
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Backfill of excavation conducted promptly
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Emergency plan provided
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Issues not currently identified in this section
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Summary of Issues if needed
Fall Protection
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If observed check box (If not checked then it is N/A)
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Supervisor present during activities
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Competent person identified and documented
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Competent person present during activies
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Competent person conducts duties as required
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JHA in place and reviewed with crew <br>
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Workers trained for task
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Worker(s) with proper PPE for activities
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Qualified equipment operators provided as needed
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Workers using fall protection as needed
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Equipment in use, inspected, maintained, and used as required.
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Appropriate anchorage for system
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Anchorage points positioned above workers
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Workers protection provided at all times
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Fall protection plan <br>
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Lifelines protected from damage
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Fall protection system designed and approved by qualified person
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Illustration of designed system provided
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Appropriate lifelines provided as needed
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Number of workers utilizing systems as desined
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No visible damage of fall protection system
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No excessive slack in system
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All system components compatible
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Labels in place and legible
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Fall protection equipment properly worn
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Fall protection system in use does not allow for pendulum swing
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Clearance from surrounding hazards maintained
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Systems installed as designed
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Guardrails free of snag, puncture, or laceration hazards
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Soft barricade/warning line offset minimum 6 feet
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Cable guardrails installed properly and identified as required
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Overhead protection provided as needed
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Emergency plan provided
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Guardrails systems properly installed and maintained
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Impalement protection provided as required
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Issues not currently identified in this section
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Emergency equipment provided
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Summary of Issues if needed
Fire Prevention & Suppression
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If observed check box (If not checked then it is N/A)
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Supervisor present during activities
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Workers trained for task
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JHA in place and reviewed with crew <br>
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Equipment in use, inspected, maintained, and used as required.
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No unapproved modifications of equipment
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No visible damage to equipment
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Permits issued and posted in the immediate work area as needed
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Worker(s) with proper PPE for activities
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Fire prevention/suppression plan provided
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Clearance from surrounding hazards maintained
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Site maintained to allow emergency response as needed
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Fire extinguishers provided and maintained as required
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Combustible/flammable materials in quantities for immediate use
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Standpipe charged as construction progresses
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Water supply provided, maintained and accessible for emergency use
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Smoking areas designated
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Gas cylinders stored and secured properly
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Waste containers provided and maintained
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Issues not currently identified in this section
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Summary of Issues if needed
Ground supported Scaffold installation / use
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If observed check box (If not checked then it is N/A)
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Competent person identified and documented
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Competent person present during activies
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Supervisor present during activities
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Workers trained for task
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Qualified equipment operators provided as needed
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JHA in place and reviewed with crew <br>
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Fall protection plan <br>
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Worker(s) with proper PPE for activities
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Workers using fall protection as needed
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Tag on scaffold indicating current status in place at access points
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Proper base (base plate, rollers, sill plates) provided
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Equipment in use, inspected, maintained, and used as required.
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No visible damage to scaffold components
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Ground support appears level stable, unobstructed, and able to support intended load
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Scaffold secured from movement
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Structural Components in place and secure
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All work levels completely decked
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Scaffold capacity documented
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Guardrails and toe boards installed
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Scaffold does not appear to be overloaded
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Access ladders provided at each level
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No apparent fall exposures from gaps or openings
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Work platform does not appear to be in excess of 8" from work face
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Materials not stacked above height of toe boards
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Rolling scaffold locked from movement during use
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Overhead protection provided as required
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Pathway of rolling scaffold level, clear, unobstructed, and able to support intended load
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Scaffold inspected and Green Tag provided once completed
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Rolling scaffold not occupied during movement
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Issue not currently identified in this section
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Summary of Issues if needed
Housekeeping
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If observed check box (If not checked then it is N/A)
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Supervisor present during activities
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Worker(s) with proper PPE for activities
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Plan to protect workers from recognized hazards
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Worker trained for proper equipment use
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Equipment in use, inspected, maintained, and used as required.
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JHA in place and reviewed with crew <br>
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No unauthorized modification of equipment
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No visible damage to equipment
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Qualified operators provided as needed
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Workers trained for task
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Trip/slip hazards controlled
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Work area cleared and unobstructed
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Clearance from surrounding hazards maintained
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Signs posted to warn of hazards
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Floor penetrations covered, secured, and identified
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Adequate lighting provided in all areas
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Construction waste properly controlled and disposed of
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Anti-slip flooring provided as needed
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Aisle unobstructed and clearly marked
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Exit signs posted and maintained as needed
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Spills, leaks, and water accumulation cleaned properly
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Waste containers provided and maintained
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Proper containers for storage and handling of materials
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Storage areas maintained and accessible
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Materials stacked and stored properly
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Round stock managed properly
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Powder shots managed properly
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All access/egress points maintained and unobstructed
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Dust control measures provided
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Pathway to emergency equipment maintained and unobstructed
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Barricades and/or signage poseted as required
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Steps/ramps provided at walkways w/ 19" elevation changes
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Areas outside of building(s) free of weeds, debris, and trash
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Issues not currently identified in this section
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Summary of Issues if needed
Ladder Usage
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If observed check box (If not checked then it is N/A)
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Supervisor present during activities
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Competent person identified and documented
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Workers trained for task
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Workers trained for proper ladder usage
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JHA in place and reviewed with crew <br>
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Worker(s) with proper PPE for activities
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Fall protection plan <br>
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Workers using fall protection as needed
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Equipment in use, inspected, maintained, and used as required.
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Labels provided and legible
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No visible damage to equipment
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Permits issued and posted in the immediate work area as needed
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No unauthorized modification of equipment
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Work area cleared and unobstructed
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Ladder properly positioned and secured from movement
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Proper use of equipment as intended
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No metal ladder in use
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Clearance from surrounding hazards manitained
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Proper ladder in use for task
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Workers maintaining proper positioning on ladder
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Ladder support appears level, stable, unobstructed, and able to support intended load
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Approach path to access ladder guarded
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Proper extension of access ladder to work platform
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Hoist rope provided at all access ladder
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Issues not currently identified in this section
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Minimum of two (2) independent means of access/egress provided from each work level
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Summary of Issues if needed
Motorized Equipment
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If observed check box (If not checked then it is N/A)
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Supervisor present during activities
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Workers trained for task
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Qualified operators identified and documented
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JHA in place and reviewed with crew <br>
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Worker(s) with proper PPE for activities
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Equipment in use, inspected, maintained, and used as required.
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Labels in place and legible
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No unapproved modifications of equipment
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Alarms/warning devices functioning properly
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No visible damage to equipment
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Operators manual provided
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Proper use of safety features by operator
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Proper use of equipment as intended
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Operator remains in control of equipment at all times
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Trained flagman/Spotter provided as needed
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Travel path or base appears level, level, stable, unobstructed, and able to support intended load
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Clearance from surrounding hazards maintained
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Permit issued and maintained as needed
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Whip checks provided at all connections on compressed air hoses
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All safety features on equipment functioning
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Issues not currently identified in this section
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Summary of Issues if needed
Project oversight
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If observed check box (If not checked then it is N/A)
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Supervisor present during activities
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Project Safety coordinator and/or Project Safety assistant(s) present during work activities
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Project safety management plan for current conditions
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Plan(s)to protect workers from recognized hazards
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Persons responsible for safety document maintenance
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Emergency action plan maintained for current conditions
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Means to ensure supervision present for all tiered contractors during work
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Means to ensure that equipment in use inspected, maintained, and used as required
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Means to ensure all workers are orientated and badges issued prior to work start
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Means to ensure daily development and submission of JHAs
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Means to communicate/re-enforce disciplinary policy
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Current chemical inventory and appropriate SDS
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Site specific safety plan for each tiered contractor
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Competent person(s) documentation for all tiered contractors
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Subcontractor safety representative (SSR) identified for each contractor
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Return to work Policies for all tiered contractors
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Project safety meeting(s) attendance
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All tiered contractors enrolled/exempted in ROCIP
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Maintenance of contractor's insurance policies
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Emergency contact information as needed
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Contact information for safety representatives and supervision for all tiered contractors
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Maintenance of minutes for all safety related meetings
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Equipment operator qualifications
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Trench safety plans
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Incident/injury reports
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Arrangements for medical treatment on site and off
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Safety related signs and posters posted as required
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First-aid equipment and supplies provided and maintained
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Drinking water management
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Sanitation management
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Perimeter fencing, gates, and public protection provided and maintained
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Vehicle paring and traffic management
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Street, curb, and sidewalk protection
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Adequate access/egress provided and maintained from all work areas
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Project visitor entry management
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Exterior lighting management
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Issues not currently identified in this section
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Summary of Issues if needed
Scissor And Aerial Lift Operation
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If observed check box (If not checked then it is N/A)
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Supervisor present during activities
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Workers trained for task
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JHA in place and reviewed with crew <br>
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Worker(s) with proper PPE for activities
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Qualified operators provided as needed
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Workers using fall protection as needed
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Fall protection plan <br>
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Equipment in use, inspected, maintained, and used as required.
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No visible damage to lift
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Labels in place and legible
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Safety features of lift operational and in use
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Alarms and warning devices functioning properly
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Operator manual provided
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Basket and ground controls functioning properly
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Workers positioned in lift as required by manufacturer
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No unapproved modifications of equipment
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Pathway of travel clear and unobstructed
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Ground support appears level, stable, and able to support intended load
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Materials in lift secured from falling
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Area below lift secured or overhead protection provided
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Clearance from surrounding hazards maintained
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Materials not stacked above height of toe baords
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Platform clear of slip/trip hazards
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Issues not currently identified in this section
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Summary of Issues if needed
Suspended scaffold
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If observed check box (If not checked then it is N/A)
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Competent person identified and documented
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Competent person present during activies
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Supervisor present during activities
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Workers trained for task
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JHA in place and reviewed with crew <br>
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Qualified operators provided as needed
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Worker(s) with proper PPE for activities
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Fall protection plan <br>
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Workers using fall protection as needed
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Equipment in use, inspected, maintained, and used as required.
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Labels on scaffold and outriggers provided and legible
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Counterweights installed per manufacture's requirements
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No visible damage to scaffold components
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Tie back cables installed and properly anchored
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Structural components in place and secure
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Lifelines protected from damage
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Guardrails and toe boards installed
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Independent lifelines provided for each worker on scaffold
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Scaffold does not appear to be overloaded
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Scaffold capacity documented
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Proper access provided to scaffold
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Work platform clear and unobstructed for worker movement
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No apparent fall exposures from gaps or openings
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Overhead protection provided as required
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Material not stacked above height of toe board
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No additional work being performed below suspended scaffold
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Scaffold insepcted and green tag provided at outrigger and scaffold platform once complete
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Issues not currently identified in this section
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Means to secure scaffold from movement after work hours
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Summary of Issues if needed
Welding & Cutting Operations
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If observed check box (If not checked then it is N/A)
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Qualified operators identified and documented as needed
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Supervisor present during activities
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Workers trained for task
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Fall protection plan <br>
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Workers using fall protection as needed
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Worker(s) with proper PPE for activities
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Equipment in use, inspected, maintained, and used as required.
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JHA in place and reviewed with crew <br>
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Labels provided and legible
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No visible damage to equipment
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No unauthorized modification of equipment
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Workers trained for fire prevention and suppression provided
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Permit issued and posted in immediate work area
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Portable fire protection provided
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Gas cylinders properly handled, maintained and stored
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Flash back arrestors installed at gauges
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Means to prevent sparks/heat from leaving immediate work area
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Clearance from surrounding hazards maintained
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Proper means to ignite cutting torch provided
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All safety features on equipment installed and functioning
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Proper eye protection for welding/cutting provided
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Welding machines properly grounded and insulated
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Flash screens provided as needed
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Issues not currently identified in this section
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Summary of Issues if needed
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Reviewed with
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Auditor
