Title Page
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Document No.
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Division
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Client / Site
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Conducted on
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Prepared by
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Location
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Supervisor
General
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Personal Protective Equipment
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Housekeeping
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Weekly Safety Meeting
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Date Given
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Job Hazard Analysis Completed
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Confined Space Program in Place
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Competent Person at Site
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Safety Signs/Warnings Posted
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Traffic Controls
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Exposed Rebar Cap
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Safety Manual On-Site
Health & Environmental
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Certified First Aid/CPR Person
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AED Location on JHA
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Monthly Inspection Date
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Drinking Water and Cups Available
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First Aid Kit Stocked
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Safety Data Sheets Available
Electrical
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Qualified Workers
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Minimum Approach Distance
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Adequate Protective Cover-Up Installed
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System De-Energized or Tagged
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Rescue Blocks
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Condition of Grounds
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Condition of Hot Sticks
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Rubber Goods Test Current
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Ground Fault Circuit Interrupter (Monthly Inspections)
Fall Protection
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Personal Fall Arrest System for Exposure 6' or Greater
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Hole Cover Procedures Followed
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Correct Anchor Point
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PFAS Inspected
Heavy Equipment
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Operators Trained
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Daily Inspection Documented
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Swing Radius Barricade
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Operator Manual Available on Equipment
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Back Up Alarms/Horn
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Seatbelt in Use
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Outriggers & Pads Used
Excavation, Trenching, Shoring
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Competent Person
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Name
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Daily Trench Inspection
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5' or Greater- Shored, Sloped, Benched, Trench Box
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4' or Greater- Safe Means of Access/Egress Within 25'
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Ladder Readily Accessible/Used Correctly
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Spoil Piles/Materials Back 2'
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Utilities Marked
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Locate Ticket Number
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Hand Dig to Identify
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Barricaded/Secured
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Protection from Water Accumulation
Material Handling
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Gloves Being Worn
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Organized
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Safe Body Positions
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Lifting Properly
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Avoid "Line of Fire"
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Aware of Pinch Points
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Tag lines Used
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Condition of Slings/Hooks/Shackles
Fire Protection
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Fire Extinguishers Available
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Employees Trained (P.A.S.S.)
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Extinguishers Checked and Tagged
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"NO SMOKING" Enforced Near Flammables
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Flammable Liquids in Approved Containers
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Equipment Shut Down Prior to Fueling
Hand and Power Tools
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Proper Tool/Correct Use
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Tool Cords/Plugs Condition
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Safety Guards in Place
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Extension Cords
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No Modifications
Cranes
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Operator Certified
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Annual Inspection Current
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Daily Equipment Checklist
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Manufacture Operator Manual
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Qualified Rigger/Signal Person
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Rated Load Capacities/Hand Signals Posted
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Outriggers and Pads Used
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Swing Radius Barricaded
Vehicles
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Seat Belts Worn
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D.O.T. log Completed & In Vehicle
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Avoid Backing/First Move Forward
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Use of a Spotter
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Accident/Incident Report Forms in Glove Box
Welding & Cutting
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Gas Cylinders Upright and Secured
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Burning/Welding/Cutting Goggles or Shields in Use
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Fire Extinguisher
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Pancake Style Welding Shield Marked ANSI Z87-1
Signatures
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General Foreman
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Foreman
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Auditor
