Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
Untitled Page
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Employee Name and Number
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Work Area or Equipment Number
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LAVG
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Is This Normal Routine Shiftwork
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What Type of Work Is Being Done
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What PPE is being worn?
- Hard Hat
- Safety Glasses
- Hi-Vis
- Ear Plugs
- Ear Muffs
- Half-Face Respirator
- Full-Face Respirator
- Steel/Composite Toe Boots
- Gloves
- None
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Is the employee Fit for Duty for their respirator if they use one?
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Is the employee wearing their ear plugs, or other hearing protection, the right way?
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Picture of Sample
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Has the employee been filling out their Task Sheet?
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If the employee is in a closed cab, how are the cab seals? Is the AC working? Is the cab clean? Are there any air leaks in the cab? etc
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Important Comments
