Title Page

  • Conducted on

  • Prepared by

  • Location

DOT and Program Compliance

  • Are there additional incentives for improving safety?

  • Remediation

  • Is Branch currently under Mendoza line?

  • Remediation

  • Are all accidents/injuries investigated/reported promptly?

  • Remediation

  • Are all temporary employees utilized and/or trained?

  • Remediation

  • Are drivers off duty 10 hours or more before returning to work?

  • Are DOT files complete and up to date?

  • Remediation

  • Does Branch have a system to maintain medical cards and driver's licenses?

  • Remediation

  • Are DOT files in locked cabinet or secure location?

  • Remediation

  • Do CDL holders drive less than 11 hours daily?

  • Remediation

  • Are drivers on clock less than 60 hours in 7 days?

  • Remediation

  • Do drivers meet 100 air mile exemption? If not, are logs complete?

  • Remediation

  • CDL holders do not operate vehicles after 14 hours on the clock?

  • Remediation

General Work Environment

  • Are controls in place to prevent unauthorized entry and theft of equipment?

  • Remediation

  • Are all work areas adequately illuminated?

  • Remediation

  • Are work areas ventilated appropriately?

  • Remediation

  • Remediation

  • Is minimum number of toilet facilities provided and sanitary?

  • Remediation

  • Is all water provided for drinking potable and if not, clearly identified? Are ice machines safe and clean?

  • Remediation

  • Are all spilled hazardous materials cleaned up immediately?

  • Remediation

  • Are break areas sanitary (kitchens, refrigerators, microwaves)?

  • Remediation

Employer Postings

  • Is an approved Panel of Physicians posted?

  • Remediation

  • Is OSHA Job Safety displayed?

  • Remediation

  • Is OSHA 300 posted?

  • Remediation

  • Is "Safety Scoreboard" being used and up to date?

  • Remediation

Branch Compliance Folder and HazCom Standards

  • Is the Branch Compliance Folder up to date?

  • Remediation

  • Is there a current hazard assessment on file?

  • Remediation

  • Is there a list of updated hazardous substances used and SDS readily available for each used?

  • Remediation

  • Is the current written exposure control plan for blood borne pathogens?

  • Remediation

  • Is there an updated written HazCom program with SDS, labeling and training?

  • Remediation

  • Is RRED ONE Plan in SDS binder?

  • Remediation

  • Are COIs on file for all vendors and subcontractors?

  • Remediation

  • Is each container labeled with product identity and a hazard warning?

  • Remediation

  • Are Hepatitis B vaccines completed or declination forms filed?

  • Remediation

Record Keeping - LF/TS

  • Scales inspected as required?

  • Remediation

  • Waste screening records completed in accordance with operations plan?

  • Remediation

  • Record from applicable agency allowing alternative daily covers available?

  • Remediation

  • Operations plan and engineering drawings available?

  • Remediation

  • Permitted stabilization/landscaping plan available?

  • Remediation

  • Permitted contingency plan available?

  • Remediation

  • Permitted groundwater monitoring plan available?

  • Remediation

  • Permitted post-closure plan available?

  • Remediation

  • Tittle V Air Permit available?

  • Remediation

  • Leachate handling permit available?

  • Remediation

Environmental Compliance and Stormwater

  • Is dust generated or tracked into roadways?

  • Is excessive debris on yard?

  • Is yard free of standing water?

  • Is NPDES Stormwater Permit or No Exposure Certification on file?

  • Are no elicit discharges detected?

  • Are stormwater ponds permitted and in compliance within maintenance agreement?

  • Are Stormwater Ponds compliant with best management practices (BMP’s)?

Environmental Compliance - LF/TS

  • Signage present to control traffic?

  • Remediation

  • Signs posted at gate displaying hours, emergency contact, no smoking, prohibited wastes, etc.?

  • Remediation

  • Leachate collection system compliant?

  • Remediation

  • Windblown debris controlled?

  • Remediation

  • Prohibited wastes effectively prevented?

  • Remediation

  • Scavenging effectively prevented?

  • Remediation

  • Vectors effectively prevented?

  • Remediation

  • Roadways maintained with berms or guardrails present if necessary?

  • Remediation

  • Final slopes are 3:1 with vegetation or seeding in process?

  • Remediation

  • Erosion effectively controlled and BMPs in place?

  • Remediation

  • Buffer areas maintained?

  • Remediation

  • Working face of manageable size in accordance with operations plan?

  • Remediation

  • Waste covered daily (MSW) or as required by permit (C&D)?

  • Remediation

  • Yard trimmings, compost, or woodchips appropriately maintained?

  • Remediation

  • Asbestos handled in accordance with permit?

  • Remediation

Medical Services and First Aid

  • Are universal precautions observed where BBP exposure can occur?

  • Remediation

  • Is medical care 3 minutes or 3 miles from workplace or an employee(s) qualified in first aid?

  • Are first aid kits accessible, inspected, and replenished as needed?

  • Remediation

  • Are first aid responders trained?

  • Remediation

  • Is there an eyewash and/or shower station for quick drenching of the eyes and body?

  • Remediation

Fire Protection

  • Are fire suppression systems inspected annually?

  • Remediation

  • Are fire extinguishers properly located, identified, mounted and accessible?

  • Remediation

  • Are fire extinguishers inspected monthly and annually?

  • Remediation

Personal Protective Equipment

  • Are safety glasses available and worn as needed?

  • Remediation

  • Are protective gloves or other means provided?

  • Remediation

  • Are hard hats required, provided, and worn?

  • Remediation

  • Do employees working on roadways wear reflective clothing (ANSI Class II)?

  • Remediation

  • Is appropriate foot protection being worn?

  • Remediation

  • Is protection against occupational noise provided?

  • Remediation

Walking Working Surfaces

  • Are aisles and passageways clear and marked?

  • Remediation

  • Are there standard guardrails where working surfaces are elevated (≥48")?

  • Remediation

  • Are floor openings guarded by a cover or guardrail?

  • Remediation

  • Are toe boards around permanent floor openings where persons would pass below?

  • Remediation

  • Can handrails withstand 200 impact pounds?

  • Remediation

  • Are signs posted showing elevated surface load capacity?

  • Remediation

  • Are handrails on stairways and elevated surfaces?

  • Remediation

  • Are all stairways at least 22" wide and risers uniform?

  • Remediation

Exit or Egress

  • Are all exits marked, illuminated and visibly marked?

  • Remediation

  • Are doors that could be mistake for exits marked "NOT AN EXIT"?

  • Remediation

  • Are all exits kept free of obstructions?

  • Remediation

  • Can exit doors be opened from direction of travel with single action?

  • Remediation

  • If exit(s) open into vehicle path are barriers and warnings provided?

  • Remediation

Machine Guarding and Lockout/Tag Out Procedures

  • Is equipment capable of movement, de-energized, blocked & locked out during servicing?

  • Remediation

  • Can equipment be tagged out if it can't be locked?

  • Remediation

  • Is stored energy (mechanical, hydraulic, etc.) released or blocked before repairs?

  • Remediation

  • Are authorized employees certified and provided with individually keyed personal safety locks?

  • Remediation

  • Can only authorized employee place or remove the safety lock?

  • Remediation

  • Is there a means to identify all employees working on locked-out equipment?

  • Remediation

  • Are a sufficient number of tags and safety padlocks provided?

  • Remediation

  • Are LOTO certification/s available?

  • Remediation

  • Is machinery securely anchored to prevent tipping or movement?

  • Remediation

  • Are all emergency stop buttons colored red?

  • Remediation

  • Are all pulleys and belts within 7 feet of the floor guarded?

  • Remediation

  • Are all moving chains and gears properly guarded?

  • Remediation

  • Fan blades: openings no larger than l/2 inch if within 7 feet of floor?

  • Remediation

Welding, Cutting, Brazing

  • Are cylinders kept away from sources of heat?

  • Remediation

  • Are empty cylinders appropriately marked and valves closed?

  • Remediation

  • Are signs posted "NO SMOKING," or the equivalent?

  • Remediation

  • Are cylinders, valves, regulators & hoses kept free of oily substances?

  • Remediation

  • When not in use, the valve is closed and gas released?

  • Remediation

  • Are fire extinguishers available for immediate use?

  • Remediation

  • Are employees who are exposed to welding & cutting protected with PPE?

  • Remediation

Compressors, Compressed Air and Cylinders

  • Are compressors equipped with pressure relief valves and gauges?

  • Remediation

  • Are safety devices on compressed air systems checked frequently?

  • Remediation

  • Are signs posted to warn of the automatic starting of the compressors?

  • Remediation

  • Are belt drive systems totally enclosed?

  • Remediation

  • When inflating tires, are clip-on chuck and an inline regulator used?

  • Remediation

  • Are compressed air receivers periodically drained (moisture & oil)?

  • Remediation

  • Are valves closed when cylinder is empty & at completion of each job?

  • Remediation

  • Are cylinders legibly marked to identify the type of gas?

  • Remediation

  • Are fuel gas and oxygen cylinders separated by distance or fire-resistant barriers?

  • Remediation

  • Are cylinders stored in areas protected from external heat sources?

  • Remediation

  • Are cylinders securely stored to prevent tipping, damaged or tampering?

  • Remediation

  • Are valve protectors placed on cylinders when not in use?

  • Remediation

Hoist, Auxiliary Equipment and Materials Handling

  • Is rated load legibly marked and visible to the operator?

  • Remediation

  • Are cranes/hoisting equipment inspected regularly?

  • Remediation

  • Are controls plainly marked to indicate the direction of travel or motion?

  • Remediation

  • Are employees prohibited from using chains or rope slings that are kinked, twisted, or otherwise damaged?

  • Remediation

  • Is there safe clearance for equipment through aisles and doorways?

  • Remediation

  • Are dock boards used when loading or unloading between vehicles and docks?

  • Remediation

  • Are trailers secured from movement (chocked) during loading and unloading?

  • Remediation

Industrial Trucks- Forklift/Yellow Iron

  • Are only trained personnel allowed to operate?

  • Remediation

  • Is warning horn and backup device clearly heard above noise?

  • Remediation

  • Are inspections done daily and taken out of services if repairs can't be made?

  • Remediation

  • Are all identification and load capacity plates legible?

  • Remediation

Confined Spaces

  • Are all moving parts inside confined spaces locked out and restrained if needed?

  • Remediation

  • Is lockout tag out always performed prior to confined space entry?

  • Remediation

  • Are employees prohibited (posted) from entering permitted confined spaces?

  • Remediation

Flammable and Combustible Materials

  • Are combustible debris and waste materials (oily rags, etc.) stored in covered metal receptacles?

  • Remediation

  • Are approved containers used to store flammables & combustibles?

  • Remediation

  • Are "NO SMOKING" signs posted on LPG tanks and where flammable/combustible materials are used or stored?

  • Remediation

  • Where corrosive liquids are drawn from storage vessels, are adequate means available for neutralizing or disposing of spills or overflows?

  • Remediation

Electrical

  • Are all outlets labeled with voltage?

  • Remediation

  • Are electrical appliances, including extension cords, grounded?

  • Remediation

  • Are multiple plug adaptors (daisy chains) prohibited?

  • Remediation

  • Are cords with cursor frayed insulation repaired or replaced promptly?

  • Remediation

  • In wet or damp locations, is ground fault provided?

  • Remediation

  • Are all disconnecting switches and circuit breakers labeled?

  • Remediation

  • Is sufficient access and working space around all electrical equipment?

  • Remediation

  • Are electrical receptacles, junction boxes, etc., provided with tight-fitting covers and unused openings/knockouts closed properly?

  • Remediation

  • Is motor located within sight of its disconnecting means or able to be locked open?

  • Remediation

Fueling, AST, and UST Compliance

  • Are employees prohibited from fueling while engine is running?

  • Remediation

  • Are fueling operations performed to minimize spillage?

  • Remediation

  • Are employees prohibited from transferring gasoline in open containers?

  • Remediation

  • Are open flames, sparking or arcing prohibited near fueling operations?

  • Remediation

  • Is smoking prohibited near fueling operations?

  • Remediation

  • Are ASTs and associated piping free of rust and obvious damage?

  • Remediation

  • Are UST system inspections (line tightness, cathode, sumps, etc.) up to date?

  • Remediation

  • Is UST operator training complete?

  • Remediation

  • Are UST emergency signage put up?

  • Remediation

  • Are spill kits available near significant sources?

  • Remediation

Containers

  • Are commercial containers labeled? (“Do Not Play On or Around or Occupy This Container”. “Stand Clear When Container is in Motion”, & “Load Evenly Container must be placed on hard level surface”)

  • Remediation

  • Are open top containers labeled with maximum loading level?

  • Remediation

Vehicles

  • Are vehicles in generally good condition?

  • Remediation

  • Are cabs clean and free of debris or unnecessary equipment?

  • Remediation

  • Is emergency equipment maintained (2- 10 lbs. of extinguishing agent, 3 reflective triangles, spill kit)?

  • Remediation

  • Is Safety Lane utilized daily?

  • Remediation

  • Is an over height device installed and used on the yard?

  • Remediation

  • Are VCR's completed daily?

  • Remediation

  • Are VCR's filed by vehicle for prior 90 days?

  • Remediation

Closing Comments

  • Closing Comments

  • Safety Representative

  • Branch Representative

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.