Audit

Job information:

Site Description, Location and Project:

Work Week & Year:

CC Name:

# of Crew Performing Elevated Work:

Days Elevated Work to Occur:

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Instructions

1. Inspect the site and submit this form each week by Wednesday noon to Apollo Admin.



2. Complete all sections on this form.

3. F.O.G. Plan must be in Foreman’s possession.

4. Any condition with a fall hazard with “Feet Off Ground” requires a Work Plan. If Feet are not required to leave ground this plan is not required.

SECTION 1: PROJECT SPECIFIC FALL HAZARDS


Ladders


Deck/Walking Working Surface Leading Edge


Scaffold and/or Staging: Falls From


Catwalk/Scaffold:


Falls From Elevation

Working from MEWP

Roof or Floor Penetrations/Openings (2” or bigger must be protected over 12” requires Safety to review)

Open steel Beam/Truss/Framework:

Working Outside of Guardrail Systems (MEWP and Scaffold)

Shaft Openings


Tank/Vessel/Equipment: Falls Into

SECTION 2: FALL PROTECTION METHODS OR SYSTEMS TO BE USED

Parapet Wall Height of 39” or Greater

Non-Engineered Scaffold (SINGLE PLANK)

Engineered Scaffold

Guardrail System

Hole Covers: Secured and Labeled

Fall protection Harness (If this is checked, Identify anchor point)

Self Retracting Lifeline (anchor point)

Embedded strut (anchor point)

Rope Grab (anchor point)

Horizontal life line (anchor point)

SECTION 3: PERSONNEL ACCESS

Ladder: A-Frame

Ladder: Extension

Personnel Lift

Catwalk








Stair Tower /Scaffold Ladder System

SECTION 4: DESCRIBE OVERHEAD PROTECTION FOR WORKERS WHO MAY PASS UNDER OVERHEAD WORK


Install Caution Tape with Signage when needed

Install Danger Tape with Signage when needed

Block Access/Egress Points Into Work Zone

Provide Spotter/Flagger in Work Zone IF NEEDED




Section 5: RESCUE PLAN OR SYSTEM

Use Life Lines/Retrieval Devices (tri pods, ect....)


Utilize Scaffolds or SINGLE PLANK

Utilize Ladder

Utilize Lift

Initiate Emergency Response:503.613.4444 or ext 4.4444




Other:

Sign Off
G/F – Foreman signature:
CC's Name:
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.