Information
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Project:
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Job#:
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Conducted on
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Prepared by
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Location
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Site Supervisor
BEHAVIOR
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A. JSA reviewed and signed?
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B. JSA for each task?
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C. Near Miss Reporting?
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D. Hazard Recognition Reporting?
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E. Permits
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F. Other
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WORK AREAS
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A. General Housekeeping
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B. Walking - Working Surfaces
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C. Unprotected Sides or Holes
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D. Impalement Hazards
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E. Sanitary Facilities
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F. Water -- Trash Receptacles
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G. Material Storage/Lay Down
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H. Clear travel path
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F. Hand wash stations
JOB SITE POSTERS
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A. All OSHA Required Posters
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B. Emergency Evacuations
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C. Emergency Contacts List
HEALTH/FIRST AID
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A. CPR/First AidTraining
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B. First Aid Kit (No Expired Items)
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C. Eye Wash Facilities in Field
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D. Access to Eye Wash
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E. Other
PERSONAL PROTECTIVE EQUIPMENT
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A. Hard Hats
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B. Safety Glasses with Side Shields
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C. Face Shield / Goggles (If Required)
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D. Respiratory Protection (If Required)
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E. Hearing Protection (If required)
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F. Clothing (FRC etc. if required)
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G. Gloves
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H. Foot Protection
FALL PROTECTION
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A. Trained Personnel (Competent Person)
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B. Worn Properly
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C. Suitable Anchorage Points
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D. Inspected/Color Coded
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E. Stored Properly
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F. Emergency Rescue Plan
LADDERS
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A. Base/Footing/Set Up
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B. Inspections/Color Coded
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C. Proper Type for Task
TOOLS AND EQUIPMENT
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A. In Good Condition
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B. Inspected/Color Coded
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C. Whip-Checks
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D. Other:
EXCAVATIONS
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A. Trained Personnel (Competent Person)
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B. Access/Egress
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C. Soil Condition
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D. Water Accumulating
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E. Shoring/Shielding/Sloping
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F. Barricades
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G. Spoil Pile
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H. Air Monitoriing
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I. Emergency Rescue Plan
CONFINED SPACE
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A. Trained Personnel (Competent Person)
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B. Attendant Trained
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C. Entrants Trained
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D. Attendant Wearing
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E. Attendant Sign In Sheet
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F. Permit Required
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G. Permit Followed
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H. Air Monitoring
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I. Emergency Rescue Plan
ELECTRICAL
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A. G.F.C.I.'s
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B. Extension Cords
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C. Power Tools
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D. Lock Out/Tag Out
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E. Assured Ground Inspected
FIRE SAFETY
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A. Hot Work Permit (if required)
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B. Fire Watch Assigned (Competent Person)
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C. Fire Extinguisher/Inspected
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D. Combustibles removed/isolated
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E. Hot Work Barricade (if required)
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F. Gas Can(s)
RIGGING AND HOISTING
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A. Capacity Tags
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B. Hooks and Latches
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C. Chain falls/Come-a-longs
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D. Tag Lines
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E. Inspected/Color Coded
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F. Designated Qualified Rigger
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G. Damage
SCAFFOLD
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A. Trained Personnel (Competent Person)
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B. Hand and Mid-rails, Toeboards
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C. Platform Decked/Secured
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D. Level Footing/Set up
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E. Access/Egress
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F. Away from Powerlines
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G. Barricades
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H. Inspection/Tagged Correctly
CRANE EQUIPMENT
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A. Crane Inspection
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B. Operator Manual
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C. Crane Setup
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D. Crane Swing Radius
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E. Flagman with Vest
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F. Operator Qualified and Certified
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G. Designated Qualified Signaller
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H. Fall Zone Procedures
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I. Lift Plan (if required)
EQUIPMENT
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A. Equipment Inspections
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B. Operator Qualified and Certified
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C. Operator Manual
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D. Flagman with Vest
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E. Proper setup and use
HAZCOM
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A. Training - Right to Know
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B. MSDS on Site
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C. MSDS for all Chemicals on Site
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D. Proper Storage of Chemicals
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E. Proper PPE for Handling Chemicals
OTHER
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A.
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B.
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C.
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D.
Comments/Recommendations
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Enter any corrective actions that will be undertaken
Sign Off
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Safety Representative
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Production Leader
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Construction Supervisor
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Field Hourly Rep / Others
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Field Hourly Rep / Others
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Field Hourly Rep / Others
