Title Page

  • Conducted on

  • Prepared by

  • Location


  • List current operations.

  • Has the JSA and all related documents been completed and filled out in accordance to the task being performed - to include one-call, excavation safety report, hot work, etc.?

  • Have the hazards associated with each job step been identified on the JSA?

  • Have the hazards identified been mitigated?

  • Were you approached by an employee to review JSA prior to entering work area?

  • Does the site have appropriate warning signs to identify hazards upon approaching location?

  • Is Foreman/Supervisor engaging employees and actively overseeing job tasks - Supervisor not operating equipment?

  • Upon arrival, are all employees wearing proper PPE?


  • Can the equipment operator provide training documentation for the piece of equipment being operated?

  • Can proof of inspection be provided for trackhoe, backhoe, etc.?

  • Have all major hazards been identified and mitigated prior to operation? Has Mechanic been notified about non-conformities on equipment?

  • Is equipment being operated in a safe manner?

  • Does equipment have owner's manual? (if not, record make, model & VIN in notes)

  • Are all lifting straps in acceptable condition? (if not, remove immediately and instruct Supervisor to retrieve replacement strap)

  • Is preventative maintenance being conducted and documented?

  • Is equipment free of excessive loose objects or trash?

  • Are all trucks (inside and outside) free of excessive loose objects or trash?

  • Do all trucks have first aid kit? Is it stocked to an acceptable level?

  • Do all trucks have fire extinguisher present and mounted properly?

  • Do fire extinguishers have annual and monthly tag affixed and in date?

  • Are fire extinguishers fully charged, have pin and breakaway tie in place, and show no signs of excessive rust or damage?

  • Are all of the following in acceptable condition - seat belts, AC, windshield, brakes, mirrors, blinkers, lights, horn, leaks, tires?

  • Are seat belts being utilized while operating mobile equipment?

Energy Control

  • Does Supervisor have assigned lock box with at least 10 locks present and labeled?

  • Have all equipment location points been identified and notated on the Energy Control Form?

  • Have all locks been applied and identified properly?

  • Are tags filled out thoroughly?

  • Is lock box in acceptable condition?


  • Are welders and helpers wearing PPE properly?

  • Is the fire extinguisher easily accessible in case of emergency?

  • Is there a designated fire watch in place that is trained and competent in extinguishing operations?

  • Are compressed gas cylinders in adequate condition and at a safe distance away from where work is being completed?

  • Was extinguisher inspected prior to selection?

  • Do grinders have guards in place?

  • All welding leads in acceptable condition with no exposed wires?


  • Have all excavations been identified and blockaded, when applicable?

  • Is excavation sloped/benched properly?

  • Is competent person for excavation on site and did competent person inspect excavation prior to entry?

  • Was the excavation tested for H2S or any other hazards prior to entry?

  • Are piles of dirt at least 2 feet away from the edge of the hole?

Working at Heights

  • Are employees tied off with acceptable devices?

  • Are all tools being used overhead tethered? If not, is the area below taped off to prevent entry of personnel to prevent fall hazard injuries?

  • Are personnel working from heights competent in doing so?

Painting and Sandblasting

  • Have all hazards related to painting or sandblasting been identified?

  • Has equipment been inspected and in good condition?

  • Is all additional PPE in acceptable condition and being utilized?

Employee Questionnaire

  • Can employees explain Energy Control Procedures?

  • Can employee explain procedures to extinguishing a fire?

  • Can employee explain topics discussed in pre-job safety meeting? (should reflect JSA hazards and mitigation steps)

  • Can employees explain hazards involved in excavation work?

  • Can employees explain hazards involved in working at heights?

  • Can employees explain hazards involved in welding and cutting?

  • Can employees explain hazards involved in driving?

  • Can employees explain hazards involved with working near "live lines"?

  • Can employees explain hazards involved with working near overhead power lines?

  • Can employees explain hazards of operating equipment without a spotter?

  • Can employees explain hazards of not wearing proper PPE?

  • Can employees explain hazards of working in hot weather?

  • Can employees explain hazards working in H2S environments?

  • Can employees explain hazards working in confined spaces?

  • Can employees explain fire prevention methods that can be used on location?

  • Can employees explain hazards related to painting or sandblasting?

  • Can employees explain the importance of the Time Out For Safety Program?

  • Can employees explain the "3 Core Expectations"?

  • Can employee explain the purpose of the Hazard Communication program?

  • Can employees explain the incident reporting procedures?

  • Additional Comments/Concerns

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.