Title Page

  • Conducted on

  • Prepared by

  • Project #

  • Location

  • JSA Complete

  • Proper permits in place

  • Heavy equipment checklist complete

  • Lift inspection complete

  • Crane inspection complete

  • SDS on site

  • Emergency phone numbers available

Job site perimeter

  • Adjacent structures and public protected

  • Perimeter warnings clearly posted

  • CAZ complete with tags and not confusing

General safety

  • Adequate light level in work area

  • Temporary lights are safely installed and guarded

  • Emergency access is maintained

  • Shafts, floor holes, and slab edges are guarded

  • 100% use of hard hat and eye protection

  • Fall arrest or restraint properly used

  • Hearing, feet, hands,faces, arms, and other parts protected

  • Toilet facilities adaquate

  • Drinking water available

  • First aid kits and eye wash stations

  • All containers are clearly marked and labeled

  • Hand tools

  • Power tools and cords inspected and have proper guards in place

  • Proper pressures and safeguards for pneumatic tools

  • GFCI used and cords have ground

  • Electric panels are clearly marked

  • Dust and silica is controlled

Heavy equipment and trucking

  • Does equipment have a safe area to operate with spotter

  • Using proper PPE to change attachments

  • Trucks don't have any debris hanging off or on tailboard

  • Loads are properly covered with secured tarp

  • Equipment is chained down and secured for transport

Fire safety and fire watch

  • Extinguishers inspected annually and monthly

  • Flammable fuels stored in proper containers

  • Fire watch trained and has extinguisher and water hose as needed

  • Combustibles removed from area of hot work

  • Equipment protected as needed with fire blanket or other means

Cranes and rigging

  • Crane operator has certification

  • Counterweight and swing radius is protected

  • Proper clearance from electric and object contact

  • Safety features are in place and functioning

  • Trained rigger and signal person

  • Rigging has been inspected before every use and is tagged and marked

  • Hooks on rigging and crane have keepers in place and functioning

Ladders

  • Ladder inspection

  • Ladder has proper angle, 3 ft above landing, tied off, and is used properly

Torching and burning

  • Condition of cables, hoses, gauges, proper torches, ect

  • Cylinders properly stored and separated when not in use

  • Flash-back arrestors used

  • Burners in FR coveralls, respirator, shaded face shield, and burning gloves

Confined Space

  • Proper signage

  • Written plan and documented training

  • Proper permits and enforced

  • Adequate rescue measures available

  • Testing equipment calibrated and used

Compressors and generators

  • Exhaust issues addressed

  • Safety features and safeguard requirements verified ( grounding)

LOTO/Air Gap

  • Equipment being removed is been airgapped and verified by a joint walk

  • LOTO procedure is being followed completely if being used

Excavation

  • Utilities clearly marked

  • Daily reports and inspections by Competent person

  • Perimeter warnings are clearly posted and barricaded and tagged

Worker safety training

  • Weekly tool box talks

  • New worker orientations complete

  • All employees have been trained to task

Other

  • Other

  • Other

  • Other

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.