Information

  • Audit Title

  • Format: Last name, First name

  • Location

  • Conducted on

  • Prepared by

  • Personnel

  • Business Unit

  • Function/Entity

  • Workgroup

  • Job Title/Work Being Performed

Accountability

  • 1a. When was the last time you were coached from a member of management on safety?

  • 1b. Can you describe the situation and did you consider it to be an effective coaching moment?

Safety Commitment

  • 2a. On a scale of 1-10, with 10 being the best, how committed are you to safety?

  • Select from range

  • 2b. On a scale of 1-10, with 10 being the best, how committed is your leadership to safety?

  • Select from range

Human Performance

  • 3a. On a scale of 1-10, with 10 being the best, how effective do you consider Human Performance to be?

  • Select from range

  • 3b. On a scale of 1-10, with 10 being very often, 5 being sometimes, and 1 being never, how often do you use Human Performance?

  • Select from range

Conservative Decision Making

  • 4a. Prior to making a decision, do you think Likelihood or Consequences?

  • 4b. What factors do you consider when making a decision?

Job Safety Assessment

  • 1. Is the tailboard/hazard assessment complete?<br> <br>

  • 2. Have the job hazards been identified, prioritized, and documented?

  • 3. Has an effective control/mitigation plan for identified hazards been developed?

  • 4. Have the following key observation points been identified, if applicable? (animal bite exposure, slips/trips/falls, ergonomics issues, Fatal 5 rules, PPE)

  • 5. Has the emergency plan been documented and understood?

  • 6. Were required Human Performance tools discussed/identified/used?

Vehicle and Worksite Setup

  • 7. Are safety cones in place?

  • 8. Are jack stands/vehicle supports being used?

  • 9. Are the wheels chocked if vehicle is on an incline?

  • 10. Is the vehicle off or out of the roadway if at all possible?

  • 11. Is the employee using traffic vest, strobes, and flashers as appropriate?

  • 12. Is the employee clear of the line of fire/paying attention to traffic in and around the work area?

  • 13. Is the work area as free from spills and obstructions as possible?

PPE and other requirements

  • 14. Is the following PPE present and in good condition? (Hard hat with chin strap, task-specific gloves, fall protection equipment, safety glasses, welding hood/sleeves/cotton hat, cutting goggles, hearing protection, grinding face shield, respiratory protection, footwear with defined heel)

  • 15. Is the employee properly dressed? (No loose clothing and appropriate for the work being performed)

  • 16. Does the employee drive without using cell phone?

  • 17. If the driver's view was obstructed, was a spotter used to back the vehicle into a parking spot?

  • 18. Is the employee using their PPE as required?

  • Hard hats may not be required unless overhead hazards exist. Are the correct gloves being used? Is fall protection being used if worked is performed at elevations over 6 feet? Safety glasses should be used within 15 feet of work area. Is the welding hood being used when welding? Cutting goggles should be used when using cutting torch. Hearing protection must be used when operating pneumatic tools and grinders. Face shields and safety glasses should be worn while grinding. Respiratory protection should be used as necessary.

  • 19. Does the employee illustrate good personal conduct, with no horseplay, etc?

Chemical Safety, First Aid, Ergonomics

  • 20. Does the employee use ergonomic mats when necessary?

  • 21. Are SDS available for all hazardous chemicals on site?

  • 22. Are safety/medical first aid equipment/goods on site and within date including gel blankets?

  • 23. Are proper lifting/carrying techniques utilized?

  • 24. Are proper pushing/pulling techniques utilized?

  • 25. Does the employee use 3 points of contact when ascending, descending, and climbing?

  • Climb and descend facing vehicle using handles and 3 points of contact.

  • 26. Is the employee using good posture and not overextending?

Tools and Equipment

  • 27. Are hand tools organized in tool boxes?

  • Tool boxes should be organized, similar tools grouped together. Drill bits and other sharp objects should be in a container or have a guard.

  • 28. Are all hand tools in good condition with no defects?

  • No homemade tools allowed, hammer heads should be snug on handles, no broken tools allowed, defective tools should be tagged and set aside.

  • 29. Are chisels and punches free of mushroomed ends?

  • 30. Are the work lights/drop cords in good working condition and have all grounds on plugs?

  • 31. Are the extension cords properly stored, in good condition with all grounds in place and no exposed wire?

  • 32. Are all air hoses in good working condition with no bulges and no pull-type quick connects?

  • Hearing protection shall be used when operating pneumatic tools; employee is not allowed to use air hose to blow debris, etc off body.

  • 33. Is lifting equipment in good condition?

  • Load rating clearly marked, safety latches in place and functioning on hooks, no frayed cables or ropes, hydraulic hoses in good condition. Check hydraulic cylinders for leaks.

  • 34. Is the fire extinguisher clearly labeled, tagged, fully charged, and inspected as required?

  • 35. Are gas cylinders properly stored and secured in place?

  • Oxygen/acetylene/argon cylinders should be capped when not in use. Twenty feet should be maintained between oxidizers and flammables, or a firewall erected at least 5 feet high and with a fire watch of at least 30 minutes. Cylinders must be protected from damage, corrosion, sunlight, and kept away from heat sources. No AC work is to be done in the field.

Vehicle/Trailer Inspection

  • 36. Are the truck bins organized?

  • 37. Are GFI breakers working on welder?

  • 38. Is 110v power supply from truck functional and plug in good condition?

  • Check GFI breaker as well.

  • 39. Do all headlights (bright and dim) and tail lights work?

  • 40. Do the parking lights work?

  • 41. Do the brake lights work?

  • 42. Do all turn signals work (left, right for front and back)?

  • 43. Do the emergency flashers (front and back) and strobe lights work?

  • 44. Do the interior cab lights work?

  • 45. Do the clearance lights work?

  • 46. Do the spotlights work (if equipped)?

  • 47. Is seat belt in functioning order in vehicle?

  • 48. Do all dash lights work?

  • 49. Does the horn work?

  • 50. Does the employee believe the brakes are in good working condition?

  • 51. Does the emergency brake work?

  • 52. Are there any cracks in the windshield that obstruct the driver's vision?

  • 53. Do the windshield wipers/washers work?

  • 54. Is the rear glass in good condition?

  • 55. Are the mirrors clean and free of cracks?

  • 56. Is the door glass in good condition?

  • 57. Are the tires excessively worn or flat (vehicle and/or trailer)?

  • 58. Housekeeping -- Is the cab and bed of truck clean and free of clutter?

  • 59. Are ladders in good condition with no visible defects, and being used or stored properly?

  • 60. Is the license plate present with working lights?

  • 61. Is the inspection tag in place and within date?

  • 62. Do the tool compartment lights work?

  • Comments

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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.