Title Page
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Company Name
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Project
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Location
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Foreman
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Conducted on
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Prepared by
Documentation
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JHA/ Work Plan filled out
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Weekly Safety Meeting/Toolbox talk
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Permit required available
Personal Protective Equipment
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Hard Hat worn
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Eye/face protection used
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Proper footwear worn
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Gloves used
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Safety Vest worn
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Body Harness properly used
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Respiratory protection used
Electrical/Hand tools/Power tools/Equipment
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Proper tool in working conditions
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Extension cords in working condition
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GFCI used
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Proper safety guard in place
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Tool handles in working conditions
Fall Protection
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Personal Fall Arrest System being used
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Safety Harness/Lanyard/Anchor point used properly as required
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Guardrail system set up as required
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Warning lines set up as required
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Safety Monitor following competent requirements
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Safety Net set up as required
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Floor openings covered, marked and secured
First aid, Fire and Hazcom
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First aid kit available and fully stocked
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Fire extinguishers available and in working conditions
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SDS labels on containers legible
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SDS available on site
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Gas cylinders upright and secured
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Fuel cans being used
Housekeeping and Sanitation
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Drinking water and cups available
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Restrooms clean and maintained
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Trash and materials disposed off properly
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Walkways/walk paths kept clear of hoses/ cords/debris
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Housekeeping maintained
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Work area proper access available
Ladder Safety
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Ladder 3ft above and secured
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Ladder condition and placement
Heavy equipment
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Heavy equipment inspected
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Load chart/angle indicator available
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Power lines clearance kept
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Back up alarm in working conditions
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Seat belt being used
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Swing radius barricaded
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Operator following manufacturer's recommendations
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Safe operations observed
Rigging procedures
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Tag lines being used on all lift and hoisting maneuvers
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Rigging equipment properly being stored when not in use
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Personnel kept clear of swing radius/lifting zone/landing zone
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Barricades being used to designate lifting area
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Signalman/Flagger performing proper and safe operations
Excavation
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Excavation properly protected
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Excavation more than 5ft, protection system being used
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Shoring, sloping, benching or trench box being used as protective system
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Spoil bank kept at least 2ft from excavation
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Ladder available
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Competent person performing excavation requirements to protect employees
Scaffold
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Competent person on site when erecting/dissembling scaffold
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Mudsills places properly
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Scaffold Inspection tag available
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Base plates secured
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Proper access and egress
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Ladder secured and 3 feet above
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Fully planked
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Guardrails in place
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Fixed to structure properly
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Personal Fall arrest system used
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Other
Additional observations
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Other observations
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Other observations
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Other observations
Pictures attached
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Attached media
Signature
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Author