Title Page

  • Document No.

  • Division

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Supervisor

General

  • Personal Protective Equipment

  • Housekeeping

  • Weekly Safety Meeting

  • Date Given

  • Job Hazard Analysis Completed

  • Confined Space Program in Place

  • Competent Person at Site

  • Safety Signs/Warnings Posted

  • Traffic Controls

  • Exposed Rebar Cap

  • Safety Manual On-Site

Health & Environmental

  • Certified First Aid/CPR Person

  • AED Location on JHA

  • Monthly Inspection Date

  • Drinking Water and Cups Available

  • First Aid Kit Stocked

  • Safety Data Sheets Available

Electrical

  • Qualified Workers

  • Minimum Approach Distance

  • Adequate Protective Cover-Up Installed

  • System De-Energized or Tagged

  • Rescue Blocks

  • Condition of Grounds

  • Condition of Hot Sticks

  • Rubber Goods Test Current

  • Ground Fault Circuit Interrupter (Monthly Inspections)

Fall Protection

  • Personal Fall Arrest System for Exposure 6' or Greater

  • Hole Cover Procedures Followed

  • Correct Anchor Point

  • PFAS Inspected

Heavy Equipment

  • Operators Trained

  • Daily Inspection Documented

  • Swing Radius Barricade

  • Operator Manual Available on Equipment

  • Back Up Alarms/Horn

  • Seatbelt in Use

  • Outriggers & Pads Used

Excavation, Trenching, Shoring

  • Competent Person

  • Name

  • Daily Trench Inspection

  • 5' or Greater- Shored, Sloped, Benched, Trench Box

  • 4' or Greater- Safe Means of Access/Egress Within 25'

  • Ladder Readily Accessible/Used Correctly

  • Spoil Piles/Materials Back 2'

  • Utilities Marked

  • Locate Ticket Number

  • Hand Dig to Identify

  • Barricaded/Secured

  • Protection from Water Accumulation

Material Handling

  • Gloves Being Worn

  • Organized

  • Safe Body Positions

  • Lifting Properly

  • Avoid "Line of Fire"

  • Aware of Pinch Points

  • Tag lines Used

  • Condition of Slings/Hooks/Shackles

Fire Protection

  • Fire Extinguishers Available

  • Employees Trained (P.A.S.S.)

  • Extinguishers Checked and Tagged

  • "NO SMOKING" Enforced Near Flammables

  • Flammable Liquids in Approved Containers

  • Equipment Shut Down Prior to Fueling

Hand and Power Tools

  • Proper Tool/Correct Use

  • Tool Cords/Plugs Condition

  • Safety Guards in Place

  • Extension Cords

  • No Modifications

Cranes

  • Operator Certified

  • Annual Inspection Current

  • Daily Equipment Checklist

  • Manufacture Operator Manual

  • Qualified Rigger/Signal Person

  • Rated Load Capacities/Hand Signals Posted

  • Outriggers and Pads Used

  • Swing Radius Barricaded

Vehicles

  • Seat Belts Worn

  • D.O.T. log Completed & In Vehicle

  • Avoid Backing/First Move Forward

  • Use of a Spotter

  • Accident/Incident Report Forms in Glove Box

Welding & Cutting

  • Gas Cylinders Upright and Secured

  • Burning/Welding/Cutting Goggles or Shields in Use

  • Fire Extinguisher

  • Pancake Style Welding Shield Marked ANSI Z87-1

Signatures

  • General Foreman

  • Foreman

  • Auditor

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.