Facility Evaluation

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Facility, Campus, or Job Location Address

• Physical location of worksite; unit, department, facility, building, loading dock, or warehouse

  Safe

  At Risk

  N/A

• <br>Name of Facility Manager, Supervisor, or Manager

  Safe

  At Risk

  N/A

• Environmental Conditions OK; Weather Hi, Lo, Factors to Consider

  Safe

  At Risk

  N/A

• Are OSHA, OSHA 300, Federal and State Required posters displayed in a common area

  Safe

  At Risk

  N/A

• Are safety signs or warning signs posted where appropriate

  Safe

  At Risk

  N/A

• Are emergency phone numbers, EAP, or other internal contact numbers posted

  Safe

  At Risk

  N/A

• Are work areas, employee parking lot, side walks, landscape, and areas around the building clean and orderly

  Safe

  At Risk

  N/A

• Are combustible scrap, debris, and waste stored safely and removed from immediate work areas promptly

  Safe

  At Risk

  N/A

• Are adequate toilets, washing facilities, wash areas, clean and sanitary

  Safe

  At Risk

  N/A

• Are work areas adequately illuminated, with 3-4' isle spacing, clean without heavy dust, or other pollution

  Safe

  At Risk

  N/A

• Are eye wash stations, emergency safety showers, fist aid kits, located in easy to access locations

  Safe

  At Risk

  N/A

Storm Water Pollution Prevention Plan

• Has a SWPPP Program been Implemented

  Safe

  At Risk

  N/A

• Is the SWPPP Sign Posted

  Safe

  At Risk

  N/A

• Is the SWPPP Log Up to Date

  Safe

  At Risk

  N/A

• Are SWPPP Surveys Available as Required

  Safe

  At Risk

  N/A

• Are SWPPP Best Management Practices (BMP's) Used

  Safe

  At Risk

  N/A

• SWPPP Entrances and Exits Identified

  Safe

  At Risk

  N/A

• Are Floatable Trash, Debris, Materials Protected by Silt Fence, Mulch Socks

  Safe

  At Risk

  N/A

• Are Storm Outfalls Clear of Trash, Debris, Construction Materials

  Safe

  At Risk

  N/A

Hazard Communication - HAZCOM

• Has a Hazard Communication Program been Implemented

  Safe

  At Risk

  N/A

• Is there a Hazardous Chemical List - Safety Data Sheets Binder or Electronic Safety Data Sheets File

  Safe

  At Risk

  N/A

• Are Bulk, Non Bulk, Flammable, and Hazardous Containers Labeled

  Safe

  At Risk

  N/A

• Are Chemicals Properly Stored

  Safe

  At Risk

  N/A

• Are Gas, Paint, Epoxy, other Flammable Liquids and Solids Stored Properly

  Safe

  At Risk

  N/A

• Have we prepared for Spills or Leaks, Hydraulic Fluid, Oil, Gas, Hazardous Chemicals, or Other Spills

  Safe

  At Risk

  N/A

• Have we Anticipated Working Near Unsafe Airborne Contaminates, like Concrete Dust, H2S, Co, Chlorine, Ammonia

  Safe

  At Risk

  N/A

• Are Acetylene, Oxygen, other Compressed Gas Cylinders Stored Safety

  Safe

  At Risk

  N/A

• Are Spill Kits Available, Absorbent Materials, Absorbent Pads, Absorbent Socks, Shovels, Brooms, Trash Liners

  Safe

  At Risk

  N/A

First Aid, Minor Emergency Center, Emergency Services

• Is there an Urgent Care facility located near the facility or campus?<br>

  Safe

  At Risk

  N/A

• Is there an Emergency Services Facility, ER, or Hospital located near the facility or campus?

  Safe

  At Risk

  N/A

• Is there a Fire or Police Department located near the facility or campus?

  Safe

  At Risk

  N/A

• Is there a CPR, AED, First Aid trained employee on this shift?

  Safe

  At Risk

  N/A

• Are First Aid Kits, AED, Eye Wash, Safety Showers, Emergency Equipment and Supplies Available? Where are they located; in the Immediate Work Area, Office Trailer, Company Vehicle, Easy to Access by Everyone?

  Safe

  At Risk

  N/A

• Are Sterile Band Aids, Eye Wash, Tweezers, Antiseptic, Gauze, CPR Protector Shield, Burn Ointment, Blood Born Pathogen Kit, Available

  Safe

  At Risk

  N/A

• Are Emergency and Non Emergency Contact Numbers Displayed in the Work Areas for Reporting all Near Misses, Incidents, Accidents, Medical Events, Urgent Care, and Emergency Situations; Fire, Police, EMT Responders

  Safe

  At Risk

  N/A

• Are Exit Doors Easily Opened from Inside and Outside

  Safe

  At Risk

  N/A

• Are Exits Clear from Obstructions

  Safe

  At Risk

  N/A

• Are Fire Extinguishers in Place, Charged, Inspected, and Clear from Obstructions

  Safe

  At Risk

  N/A

General Safety

• General Appearance; i.e. Company Vehicle Parking , ADA Signs, Parking Stipes, Entrance - Exit Signs, EE Ramps, Painted Striping, Stop-Warning-Cautions Signs, Fences, other Safety through Design Considerations, Production Vehicle Traffic, Employee Vehicle Traffic, Pedestrian Traffic Concerns

  Yes

  No

  N/A

• Are Passageways, Walkways Clear in Common Work Areas, Free from Slippery Conditions

  Safe

  At Risk

  N/A

• Are Passageways, Walkways, Clear in Storage or Lay Down Areas, Free from Hazardous Conditions

  Safe

  At Risk

  N/A

• Do Work Areas Have Adequate Lighting, for Day or Night Operations

  Safe

  At Risk

  N/A

• Are Workers Provided with a Flashlight or Other Portable Light Provided Nearby before Entering Dark Holds, Compartments, or Other Spaces

  Safe

  At Risk

  N/A

• Are Materials Stored in Their Designated Place and Stored or Stacked to Avoid Fall or Collapse

  Safe

  At Risk

  N/A

• Have Obstructions Been Eliminated from Routine Pathways such as Holes, Loose Boards, Lumber that Could Produce Splinters

  Safe

  At Risk

  N/A

• Are Hoses, Electrical Cords, and Service Cords Positioned to Prevent Injury, or Slip, Trip and Fall Hazards

  Safe

  At Risk

  N/A

• Have Nails, Screws, or Puncture Hazards Removed from Walkways, Removed from Work Area, Positioned with Safety in Mind

  Safe

  At Risk

  N/A

• Have Impalement Protections Been put in Place, like Silt Fence, Mulch Socks in Good Condition

  Safe

  At Risk

  N/A

• Has Trash Picked Up, Disposed of Regularly, Placed in Correct Containers

  Safe

  At Risk

  N/A

• Are Lunch Areas Clean, Common Areas Clean, Break Areas Clean

  Safe

  At Risk

  N/A

• Are Workers are Communicating Clearly at Acceptable Volume, No Shouting

  Safe

  At Risk

  N/A

• Are Restroom Clean, Portable Rest Room Clean, Free From Trash

  Safe

  At Risk

  N/A

• Do we Have the Correct Number of Fire Extinguishers, Fully Charged, Inspected and Up to Date

  Safe

  At Risk

  N/A

• Is Potable Drinking Water Available, Sanitary Disposable Drinking Cups

  Safe

  At Risk

  N/A

• Is Soap, Hand Cleaner, and or Sinks Available to Wash Hands

  Safe

  At Risk

  N/A

• Are other Construction Tools Undamaged, Have Safety Guards in Place As Designed by the Manufacture

  Safe

  At Risk

  N/A

• Are Other Hand Tools, Equipment Undamaged, No Homemade Hand Tools

  Safe

  At Risk

  N/A

• Are the Correct Tools Being Used for the Scope of Work

  Safe

  At Risk

  N/A

• Overall, Are Workers Using Safe Work Methods

  Safe

  At Risk

  N/A

• Are Employees Working at a Safe Pace, Not Running or Climbing over Object Unsafely

  Safe

  At Risk

  N/A

• Are There Enough Garbage Cans in Designated Break Areas and Other Locations Where Trash May Accumulate

  Safe

  At Risk

  N/A

• Overall Housekeeping in Good Condition; Free from Trash, Paper Cups, Scrap Materials, Water Bottles, and Other Objects

  Safe

  At Risk

  N/A

Confined Space

• Are Confined Space Non-Permit Work Areas Safe, Free from Atmospheric Hazards, LOTO in Effect

  Safe

  At Risk

  N/A

• Have Confined Space Non-Permit Atmospheres been Tested Prior to Entry, with Continuous Testing While Competing Task, Supervisor knows Which Employees Working in Confined Space, Supervisor Periodically Checks on Employees, Supervisor Notified of Any New or Changing Hazards, Entry and Exit Points, Ladders Available,

  Safe

  At Risk

  N/A

• Has the Confined Space Non-Permit Equipment; PPE, Atmospheric Testing Device, Communications Equipment, Alarm Systems, Rescue Equipment been Established

  Safe

  At Risk

  N/A

• Has a Correct Confined Space Work Permit Issued by Client, Issued by Supervisor, Or Required for Atmospheric Hazards

  Safe

  At Risk

  N/A

• Has the Confined Space Work Permit; Entry Supervisor Completed Permit, Attendant Assigned, Entrants Assigned, Recorded on CSP Log

  Safe

  At Risk

  N/A

• Does the Confined Space Work Permit Communicate Hazards to Entrants, With Atmosphere Continuously Monitored, Safe Entry and Exits, Proper PPE, Ventilation According to Hazards, Emergency Communication, Surface Rescue Equipment in Place, Harness, Lifeline, Man Basket, Supervisor Informed of New or Changing Hazards, All Employees Accounted listed on the Sign In /Out sheet, Permit Cancelled by Supervisor

  Safe

  At Risk

  N/A

Excavation and Trenching

• Who is the Competent Person Monitoring the Work on the Excavation or Trenching Task

  Safe

  At Risk

  N/A

• Is Daily Inspection Complete for the Excavation Equipment, i.e. Front end Loader, Back Hoe, Excavator, Skid Stear

  Safe

  At Risk

  N/A

• If Trenching 4 + feet ; Has it been Inspected by Competent Person, Benching, Sloping, Shoring, Equipment Used According to Plan, Manufacture Design, or Engineering Design

  Safe

  At Risk

  N/A

• Are Spoils back 2ft, Entry -Exits within 25 ft, Open Areas Covered, Fenced, or Barricaded to Protect Workers and Pedestrians

  Safe

  At Risk

  N/A

• Have Ladders, Ramps, or Other Means of Egress been established no more than 25' of lateral travel, for the employees

  Safe

  At Risk

  N/A

• Are Other Hazards Eliminated or Controlled; i.e. Atmospheric Hazards, Continuously Tested, Documented

  Safe

  At Risk

  N/A

Personal Protective Equipment - PPE

• Are Company Uniforms, High Visibility Clothing, Safety Vest, Body, Limb, and Foot Protection Acceptable

  Safe

  At Risk

  N/A

• Are the Correct Forms of Eye- Face Protection Being Used for the Task Being Completed; i.e. Cutting, Welding, or Grinding

  Safe

  At Risk

  N/A

• Are the Correct Hand Protection, Gloves, Hard Hats, Proper Footwear, Safety Vest Being Used for the task

  Safe

  At Risk

  N/A

• Is Hearing Protection Worn in Designated Areas, or Areas Where it Noise Exceeds 85 dBA

  Safe

  At Risk

  N/A

• Are Hard Hats, Double Hearing Protection, Extra PPE Safeguards needed for any task on this shift

  Safe

  At Risk

  N/A

• Fall Protection 6 + feet, Fall Arrest Systems, Retractable Lifelines, Lanyards; Full Body Harness, Worn Properly, Tied Off, Anchored Securely, Inspected by Workers

  Safe

  At Risk

  N/A

• Is Additional PPE Used When Required; Does it Meet or Exceed OSHA Standards

  Safe

  At Risk

  N/A

• Is PPE and Fall Protection Use Above Average for the Scope of Work Being Performed

  Safe

  At Risk

  N/A

• Respiratory Protection, Dust Mask, or Full Face Respirator Required for any task on this shift

  Safe

  At Risk

  N/A

Electrical, Power Tools, Extension Cords

• Are There any Exposed Electrical Hazards, Open or Damaged Control Panels, Bare or Exposed Wires, or other Electrical Hazard Concerns

  Safe

  At Risk

  N/A

• Are Electrical Cords Free of Defects, i.e. Tool, Extension Cords,Temporary Wiring, or Temporary Lighting with Double Insulated Cords

  Safe

  At Risk

  N/A

• Are GFCI's being used? Are extension cords organized, neat, and free from generating trip, slip, or fall hazards

  Safe

  At Risk

  N/A

• Are Electrical and Stored Energy Sources Locked Out or Tagged Out, Secured and Organized with a Group LOTO Box, and clearly communicated to the Site Supervisor, or Lead Craft Personnel on this shift

  Safe

  At Risk

  N/A

Scaffolding and Aerial Lifts

• Are Employees Properly Trained, having wallet cards on their person to demonstrate

  Safe

  At Risk

  N/A

• Has the scaffold been inspected by a Competent Person, prior to use? Is it tagged and easy to read

  Safe

  At Risk

  N/A

• Is the Ground Condition Adequate, with Ground Anchors, Base Plates, Mud Sills, Screw Jacks, Fasteners, or Tie Downs

  Safe

  At Risk

  N/A

• Is Proper Footing; Safe Tie-In to Structure, Wheels Locked on Portable Units, All X Braces Installed, Gates on Access Points, Safe Planking Properly Installed, Toe Boards Installed, Guardrails Installed, Proper Access, In Safe Working Condition

  Safe

  At Risk

  N/A

• Are Top Rails, Mid Rails, Toe Boards Cross Bracing, Type and Condit on of Planks Correctly Assembled

  Safe

  At Risk

  N/A

• Are Employees Tied Off if Required, Using the Aerial Lifts Safely, As Designed

  Safe

  At Risk

  N/A

• Are Personnel Lifts, Scissor Lifts, Telescopic Boom Lifts, Any Combination of Lifts; Pre Shift Inspected, Visually and Mechanically

  Safe

  At Risk

  N/A

• Are Work Zone Safe, Away from Drop Offs, Overhead Clearance, Overhead Electrical Lines, Unstable Surfaces, Slopes, Ditches, Utility Lines, High Wind, Debris, Floor Openings, Obstructions, Inadequate Ceiling Heights,

  Safe

  At Risk

  N/A

• Are Fall Protection Gates Closed, Workers Tied Off, Standing on the Platform, Not Climbing or Leaning Over Guardrail, Using Full Body Harness Tied to the Aerial Lift

  Safe

  At Risk

  N/A

• Are Workers Using Safe Operations, Traveling, Loading, Not Using the Equipment as a Crane, Not Carrying Object Larger than the Platform

  Safe

  At Risk

  N/A

Heavy Equipment; Cranes, Excavators, Front End Loaders, Back hoe, Track Hoe

• Are Annual Inspections Current, Daily Inspections Complete, Fire Extinguishers Available, Swing Radius Protected with Barricaded, Outriggers Fully Extended; Safely Positioned, Level, In Safe Operating Condition, Load Charts Available, No Hydraulic Leaks, Decals in Good Condition, Hooks Have Safety Latches, Tag Lines Available, Hand Signals Posted,

  Safe

  At Risk

  N/A

• Is Daily Inspection Complete for the Crane, Rigging, Shackles, Spreader Bars, other Specialty Lifting Gear, with Certificates Available

  Safe

  At Risk

  N/A

• Is the Equipment Positioned on Firm and Level Surface, Away from Drop Offs, Unsafe Overhead Clearance, Overhead Electrical or Power Lines, Crane Operator Using Load Charts, Not Exceeding the Rated Capacity of the Crane and Rigging Planned for the Lift

  Safe

  At Risk

  N/A

• Is the Operator and Rigger Using ANSI Hand Signals, Clear Path, Angle for Lifts and Lowered, Using Tag Lines, Maintain 10 ft from Power Lines, Ensure Rotating Parts, Other Moving Parts, or Equipment is Guarded, to Avoid Contact with Workers

  Safe

  At Risk

  N/A

• Have we Inspected Rigging and Wire Rope Prior to Use, Tagged Properly, No Damage or Deformities, Rigging is Not Loaded in Excess of Manufacture Safe Working Load Limits, Stored in Safe Area so Not to Present a Hazard, No Make Shift Rigging, Pad or Soften Rigging from Sharp Edges, Not Shock Loaded

  Safe

  At Risk

  N/A

• Have we Inspected the Heavy Equipment Before Each Shift, by a Competent Operator, Are Back Up Alarms Working, ROPS Installed, Operator Using Seat Belt, No Broken Windows Interfering with Operator, The Unit is In Safe Operating Condition, Steers Properly, No Physical Damage

  Safe

  At Risk

  N/A

• Safe Operations, Traveling in and Out of Work Zones, Staying Clear of Utilities, Other Contractors, Using Spotters as Needed

  Safe

  At Risk

  N/A

• Is the Work Zone Around the Crane Clean, Without Trash, Debris, or Construction Materials to Avoid Slip, Trip, Falls

  Safe

  At Risk

  N/A

• Is the Crane Exterior and Interior Clean, Free from Trash, Oil, or Other Slippery Materials to Avoid Falling When Climbing Up or Down

  Safe

  At Risk

  N/A

• Are Back up Alarms, Horns, Whistles, or another Audio Warning Devices Being Used

  Safe

  At Risk

  N/A

• Are Safe Work Methods Being Used; Hand Signals, Audio Signals, 2 -Way Radios, Extra Communication in Use

  Safe

  At Risk

  N/A

Trip and Fall Safety

• Are Walking-Working Surfaces even and uncluttered

  Safe

  At Risk

  N/A

• Are Entry and Walkways Kept Clear

  Safe

  At Risk

  N/A

• Are Intersections Kept Clear of Boxes, Storage Containers, and Other Materials

  Safe

  At Risk

  N/A

• Are Floor Surfaces Free of Liquids or Spills

  Safe

  At Risk

  N/A

• Are Stairs and Risers Kept Clear

  Safe

  At Risk

  N/A

• Are Railings in Good Condition, Free from Defects or Damage that Might Contribute to an Accident

  Safe

  At Risk

  N/A

Ladders

• Are Workers Inspecting the Ladders to Ensure They Are in Good Working Condition

  Safe

  At Risk

  N/A

• Are the Ladders Safe for Electrical Work, Non Conductive, Away from Power Lines

  Safe

  At Risk

  N/A

• Are the Ladders the Right Size for the Tasks, to Avoid Overreaching, or Standing At or Near the Top of the Ladder

  Safe

  At Risk

  N/A

• Are the Ladders Feet Working Properly, Have Slip Resistant Pads, and Positioned Correctly on a Firm and Level Base

  Safe

  At Risk

  N/A

• Are Workers Using Towlines, a Tool Belt, or Assistant to Convey Materials so that the Workers Hands are Free When Climbing

  Safe

  At Risk

  N/A

• Is the Base of a Strait Ladder(s) out 1 ft for every 4 ft, of Height to the Point of Support

  Safe

  At Risk

  N/A

• Are the Workers Using 3 Points of Contact While Climbing ( 1 hand and 2 feet or 2 hands and 1 foot)

  Safe

  At Risk

  N/A

• Are the Ladders Placed Away from Doors or Entrances, or Have the Entrance's been Blocked off or Barricaded

  Safe

  At Risk

  N/A

• Are Fall Preventative Measures in Place and Used Where Gaps Occur in Railings.

  Safe

  At Risk

  N/A

• Are Workers Below Protected From Falling Materials, i.e. Tools, Bolts, Construction Materials

  Safe

  At Risk

  N/A

Inspection Summary

• Summary Notes with Observation Attributes, Deficiencies, and Concerns

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