Information

  • Job Name

  • Job Number

  • Site

  • Location
  • Conducted on

  • Prepared by

  • Supervisors Name

  • Weather

  • Temp

Equipment

    Add Equipment and Tools
  • Equipment

  • Quantity

Man Power

  • Superintendent

  • Number

  • General Foreman

  • Number

  • Foreman

  • Number

  • Journeyman

  • Number

  • Apprentice

  • Number

  • Material Handler

  • Number

  • Safety

  • Number

  • QA / QC

  • Number

  • Construction Wireman

  • Number

  • Construction Electrician

  • Number

  • Office/Support Staff

  • Number

Daily Tasks

    Work in Progress
  • Work in Progress Today (Who, What, When, Where, Why)

  • Five main hazards
    1. Life safety - egress, emergency response, fire protection
    2. Fall hazards
    3. Electrical hazards
    4. Caught in hazards
    5. Struck by issues- vest, material handling, moving equipment

  • Hazards

  • Abatement (Corrective Action)

  • Add media

Job Factors

  • Impacts to the job

  • Materials received

  • Phone calls / Visitors

Safety Requirements

  • Does everyone have the following

  • Hard Hat

  • Safety Glasses, Face Shield, Goggles

  • Proper Foot Ware

  • Proper Gloves

  • Lock Out / Tag Out

  • Hot Work PPE

  • Meters / Testers

  • Fall Protection

  • Trench Safety Equipment

  • Confined Space Equipment

  • Hearing Protection

  • Respirator

  • Stretch & Flex

  • Monthly AED Check

  • Comments:

Personnel

Personnel

    Add Personnel
  • Employee #

  • Employee Name

  • Employee Title

  • Signature

Comments

    Add comments
  • Employee Name

  • Comments

Review

  • Signature of Supervisor

  • Signature of Director or Vice President

Incident

  • If this is an ACCIDENT please fill out an Accident report (This is a different form!)

    Accident - undesired event that CAUSES HARM or damage to people, property, or process. (Not always an OSHA recordable)
    Examples:
    Cut that could require first aid (including bandaid).
    Used eye wash station to remove foreign body.
    Vehicle accident resulting in damage with or without personal injury.

    Incident - undesired event that under slightly different circumstances COULD have caused harm to people, property, or process. (Near Miss)
    Examples:
    Almost get struck by a loader on job site.
    Carrying iPad up a ladder without a hands free strap. (could not maintain 3 points of contact)

  • Add New Incident
  • Type

  • Severity

  • Review if this should be an Accident!

  • Description

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.