HAZCOM (1910.1200)
MSDS available on site?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Hazardous work permit completed and signed?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Have critical tasks been identified on permit?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Project specific JHA available?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Is JHA being followed?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Daily Safety meeting held & attended by crew?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Emergency & Post Emergency Response (1910.120)
SSHASP completed?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Safety plan signed by crew?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Chapters 1 - 12 attached to chapter 13?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Task specific hazardous work plan completed?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
PERSONAL PROTECTIVE EQUIPMENT (1910.132)
PPE identified on permit or JHA matches what is being used?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
PPE appropriate for task?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
PPE being properly worn by crew ?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Respiratory Protection being utilized ?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
AIR MONITORING
Appropriate air monitoring being conducted?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Air monitoring instruments properly calibrated?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Readings properly documented?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Action Levels being adhered to ?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Is continuos CO monitoring required
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
EMERGENCY PREPAREDNESS
Appropriate size first-aid kits on site, available and stocked?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Minimum of two First-aid/CPR trained personnel on site? (where appropriate)
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Safety shower, or hose and eye wash in immediate vicinity when working with acids or caustics?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Emergency numbers obtained, posted and means to contact emergency services posted?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Location of nearest hospital documented and known by crew?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
ELECTRICAL SAFETY
Is equipment appropriate for the location (e.g. U/L listed Class 1 Division 1 for flammable locations?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Is an operable Ground Fault Circuit Interrupter (GFCI) used on all equipment? (Where appropriate)
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Are equipment leads and extension cords in good repair?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
FIRE SAFETY
Are a sufficient number of fire extinguishers present?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Are all extinguishers inspected with tags attached?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
For flammable/combustible transfers, has bonding and grounding been performed?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Has bonding and grounding been checked for continuity?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Have all ignition sources been eliminated?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Is LEL area monitoring been conducted?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
HOT WORK
Is the Hot Work permit properly completed?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Are available fire hoses, sprinklers or extinguishers in good repair?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Hot work equipment (torches, welders, grinders) in good repair?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Have containers, tanks or vessels been inerted to less than 8% oxygen?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Have explosive atmospheres been eliminated (35 feet)?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Have all wall and floor openings been covered (35 feet)?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Are welding blankets being utilized where necessary?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Has paint or coatings been removed from the area where the hot work will be conducted?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Have all combustible & flammable materials/liquids been removed from the area (35 feet)?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Has a fire watch been maintained for 30 minutes after completion of the hot work?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
LOCKOUT / TAGOUT (1910.147)
Have all types of energy been de-energized?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Is a LO/TO Permit completed and available?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Do all affected employees have locks applied?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Are all other LO/TO Procedures being followed?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
EXCAVATION/TRENCHING (1926.651-652)
Is there a competent person on site?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Have all utilities been identified or marked?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Is there a ladder available in the excavation for every 25 feet of travel distance?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
For excavations over 4 feet, are sloping or shoring options being followed?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Are excavation spoils located at least 2 feet from the edge of the excavation?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Is standing water in the excavation being controlled?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
If no personnel entry is required has a "no-mans-land" been established 3/4 of the excavation depth away from the edge?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Has the excavation been evaluated for confined space hazards?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Pressure Washing
Are hoses protected by whip checks?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Are hoses connected by threaded unions?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Is the wand at least 48 inches long?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Shin guards/metatarsals used?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Flex Lancing/Line Moling
Stinger at least 1.5 X pipe diameter used?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Anti withdrawal device used?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Lance maked 3 feet from tip?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
HIGH PRESSURE WATER JETTING
Has the HPWJ checklist been completed & signed?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Hoses pressure tested & tagged?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Work area barricaded & HPWJ signs posted?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Are whip checks utilized?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Metatarsal guard/shin guards used?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Medical cards carried by all personnel?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Shot Gun Lancing Manual Flex Lancing
Lance protector used?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Stinger used?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Anti-withdrawal devices used & appropriate size?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Lance marked 3-feet from tip?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Body armor worn at all pressures?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Lance operator can access foot pedal?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Remote Cleaning
Foot pedal being used?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
SCAFFOLD & ELEVATED LIFT SAFETY (1910.128)
Competent Person on site?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
All personnel "User" trained?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Scaffolding erected according to guidelines?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Daily inspection documented?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Inspection tag or equivalent attached to scaffold?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Are all components in good working condition?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Load limits documented and followed?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Work platform complete with top rail, middle rail and toe boards?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Aerial lifts
Manual reviewed by operator?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Daily inspection completed?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Full body harness and lanyard used in basket?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
VACTOR SAFETY
Electric vacuum relief or in-line tee being utilized?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Vacuum relief manned and in line of sight of hose end?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Hands & feet kept a minimum 2' from the end of the hose?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Double hearing protection used?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Hose secured to prevent "bucking"
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
WORKING ON OR NEAR WATER
Has the boat operator been certified by CHES?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Has a boating safety checklist been completed?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Are appropriate PFD's being used?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
FALL PROTECTION (GREATER THAN 6 FEET)
Are harnesses and appropriate lanyards being worn?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Are anchor points of sufficient strength (i.e.. 5000 capacity)
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
If no harness/lifelines are utilized, has a warning line been placed at least 6 feet from the edge?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Abrasive Blasting (including CO2/dry ice) MISCELLANEOUS SAFETY ITEMS
Have appropriate smoking and eating areas been designated?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Is the work zone properly barricaded or secured?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Are appropriate work zones (hot deacon support) established and sufficient?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Is the system of communication utilized by the crew sufficient?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
Is the lighting utilized on the site sufficient to safely illuminate the work zone?
Acceptable
Deficient
Correct Immediately
Further Action Required
Non Applicable
GENERAL SITE CONDITIONS OR COMMENTS
Site Conditions?
Excellent
Good
N.I.
Poor
Unsatisfactory
Comments Action Items
Description
REVIEWED H&S MANAGER:
Sign
SUPERVISOR / FOREMAN
Sign
link copied
jerry trefethen
Field Service Site Safety Inspection
Field locations inspection form
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.
