Information

  • Project:

  • Job#:

  • Conducted on

  • Prepared by

  • Location
  • Site Supervisor

BEHAVIOR

  • A. JSA reviewed and signed?

  • B. JSA for each task?

  • C. Near Miss Reporting?

  • D. Hazard Recognition Reporting?

  • E. Permits

  • F. Other

WORK AREAS

  • A. General Housekeeping

  • B. Walking - Working Surfaces

  • C. Unprotected Sides or Holes

  • D. Impalement Hazards

  • E. Sanitary Facilities

  • F. Water -- Trash Receptacles

  • G. Material Storage/Lay Down

  • H. Clear travel path

  • F. Hand wash stations

JOB SITE POSTERS

  • A. All OSHA Required Posters

  • B. Emergency Evacuations

  • C. Emergency Contacts List

HEALTH/FIRST AID

  • A. CPR/First AidTraining

  • B. First Aid Kit (No Expired Items)

  • C. Eye Wash Facilities in Field

  • D. Access to Eye Wash

  • E. Other

PERSONAL PROTECTIVE EQUIPMENT

  • A. Hard Hats

  • B. Safety Glasses with Side Shields

  • C. Face Shield / Goggles (If Required)

  • D. Respiratory Protection (If Required)

  • E. Hearing Protection (If required)

  • F. Clothing (FRC etc. if required)

  • G. Gloves

  • H. Foot Protection

FALL PROTECTION

  • A. Trained Personnel (Competent Person)

  • B. Worn Properly

  • C. Suitable Anchorage Points

  • D. Inspected/Color Coded

  • E. Stored Properly

  • F. Emergency Rescue Plan

LADDERS

  • A. Base/Footing/Set Up

  • B. Inspections/Color Coded

  • C. Proper Type for Task

TOOLS AND EQUIPMENT

  • A. In Good Condition

  • B. Inspected/Color Coded

  • C. Whip-Checks

  • D. Other:

EXCAVATIONS

  • A. Trained Personnel (Competent Person)

  • B. Access/Egress

  • C. Soil Condition

  • D. Water Accumulating

  • E. Shoring/Shielding/Sloping

  • F. Barricades

  • G. Spoil Pile

  • H. Air Monitoriing

  • I. Emergency Rescue Plan

CONFINED SPACE

  • A. Trained Personnel (Competent Person)

  • B. Attendant Trained

  • C. Entrants Trained

  • D. Attendant Wearing

  • E. Attendant Sign In Sheet

  • F. Permit Required

  • G. Permit Followed

  • H. Air Monitoring

  • I. Emergency Rescue Plan

ELECTRICAL

  • A. G.F.C.I.'s

  • B. Extension Cords

  • C. Power Tools

  • D. Lock Out/Tag Out

  • E. Assured Ground Inspected

FIRE SAFETY

  • A. Hot Work Permit (if required)

  • B. Fire Watch Assigned (Competent Person)

  • C. Fire Extinguisher/Inspected

  • D. Combustibles removed/isolated

  • E. Hot Work Barricade (if required)

  • F. Gas Can(s)

RIGGING AND HOISTING

  • A. Capacity Tags

  • B. Hooks and Latches

  • C. Chain falls/Come-a-longs

  • D. Tag Lines

  • E. Inspected/Color Coded

  • F. Designated Qualified Rigger

  • G. Damage

SCAFFOLD

  • A. Trained Personnel (Competent Person)

  • B. Hand and Mid-rails, Toeboards

  • C. Platform Decked/Secured

  • D. Level Footing/Set up

  • E. Access/Egress

  • F. Away from Powerlines

  • G. Barricades

  • H. Inspection/Tagged Correctly

CRANE EQUIPMENT

  • A. Crane Inspection

  • B. Operator Manual

  • C. Crane Setup

  • D. Crane Swing Radius

  • E. Flagman with Vest

  • F. Operator Qualified and Certified

  • G. Designated Qualified Signaller

  • H. Fall Zone Procedures

  • I. Lift Plan (if required)

EQUIPMENT

  • A. Equipment Inspections

  • B. Operator Qualified and Certified

  • C. Operator Manual

  • D. Flagman with Vest

  • E. Proper setup and use

HAZCOM

  • A. Training - Right to Know

  • B. MSDS on Site

  • C. MSDS for all Chemicals on Site

  • D. Proper Storage of Chemicals

  • E. Proper PPE for Handling Chemicals

OTHER

  • A.

  • B.

  • C.

  • D.

Comments/Recommendations

  • Enter any corrective actions that will be undertaken

Sign Off

  • Safety Representative

  • Production Leader

  • Construction Supervisor

  • Field Hourly Rep / Others

  • Field Hourly Rep / Others

  • Field Hourly Rep / Others

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.