Title Page
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Document No.
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Audit Title
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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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Personnel
General Information
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Today's Date
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Project Name
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Job Site Address
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Project Owner
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Projected Start Date
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Projected End Date
Emergency Contact Information
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General Superintendent
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Phone
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Superintendent
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Phone
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Project Manager
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Phone
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# of Laborers
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# of Operators
Utility Protection
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Has a locate ticket been opened?
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If yes, by whom was it opened?
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When was is opened?
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One Call Confirmation #
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Has this information been forwarded to the Safety Administrator for updating?
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(You should be receiving an email notification upon renewal. If not please notify Administrator.)
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Are there any known utility locations?
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Explain
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Are there any foreseeable utility concerns? (i.e. Over-head power lines, power line clearances, fiber optics, high pressure underground gas lines?)
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Explain
Equipment Fueling and Tank Protection
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Will you have a fuel tank on site?
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What size tank will be on site?
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Tank #
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Where will the tank be located?
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How will the tank be protected?
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Grounding
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Placarding
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Fire Extinguishers
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Spill Kit
Evaluating the Work Area (Mark Yes or No)
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Have you walked the job site?
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Are you working around live systems? (i.e. Power lines, traffic, operating facility)
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Does this job require site specific training? (Owner orientation, 40 hour HAZWOPER, OSHA 10/30, CPR/First Aid)
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Is an SDS review necessary for this task? (Will employees be handling or be exposed to unusual chemicals)
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Will monitoring be required in this job? (Silica, lead, noise, vibration)
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Are there owner required work permits? (i.e. Excavation, hot work, FAA)
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Will this job require the use of a crane?
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Will this job potentially expose employees to falls?
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Will this job involve working in a confined space?
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Will this job require employees to work near water?
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Is there a safety issue that has not been addressed? If so, please list here:
Potential Hazard Checklist (Mark if Applicable)
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Pinch Points
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Thermal Burns
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Particles in Eyes
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Elevated Work
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Housekeeping
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Electrical Shock
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Chemical Burns
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Fire/Explosion
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Inadequate Access
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High Noise Levels
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Falling Objects
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Manual Lifting
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Chemical Spill
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Paint Operations
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Scaffolding
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Mobile Equipment
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Heat Exhaustion/Stress
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Sharp Objects or Tools
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Radiation
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Excavations
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Hazardous Chemicals
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Lockout/Tag Out
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Ladders
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Rigging
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Falls (6' or Greater)
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Confined Spaces
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Line Breaking
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Inhalation Hazard
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Critical Lift
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Aerial Lift
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Traffic Control
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Bio-Hazards (Wildlife)
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Additional Hazards:
Employee Training Checklist
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Fall Protection
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T/E Competent Person
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Confined Space
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OSHA 10
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OSHA 30
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First Aid
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CPR
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Competent Person Rigging
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NCCO (Crane Operator)
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Crane Signaling
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Lull
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Skid-Steer
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Scaffolding
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Aerial Lift
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HAZWOPER
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(GHS) Hazardous Chemicals
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PPE
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Radiation
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Ladders
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Silica Awareness
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Lead Awareness
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Respiratory Protection
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Traffic Control
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Bio-Hazards (Wildlife)
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Additional Training:
Personal Protective Equipment (PPE) Hazard Assessment Checklist
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Select date
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Reviewer (Print)
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Project
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Description
Hand Hazards
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Chemical Exposure
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High Heat/Cold
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UV/IR Radiation
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Electrical Shock
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Puncture
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Cuts/Abrasions
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Other:
Body Hazards
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Chemical Exposure
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High Heat/Cold
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Impact/Compression
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Electrical Arc
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Cuts/Abrasion
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Falls
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Other:
Eye Hazards
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Chemical Exposure
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High Heat/Cold
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Dust/Flying Debris
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Impact
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UV/IR Radiation
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Other:
Head/Neck/Face Hazards
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Chemical Exposure
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Dust/Flying Debris
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Impact
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UV/IR Radiation
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Electrical Shock
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Noise
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Other:
Foot Hazards
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Chemical Exposure
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High Heat/Cold
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Impact/Compression
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Electrical
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Puncture
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Slippery/Wet Surfaces
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Falling Objects
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Other:
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The signature on this document certifies that a hazard assessment required by OSHA 29 CFR 1910.132, has been performed of the above identified project.
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Signature of Reviewer:
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Date:
Subcontractor Insurance Checklist
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If you answer yes to any of the questions below you should contact the Risk Management Coordinator (Kellie Tallentire) to ensure proper coverage.
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Operate Cranes
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Work off a barge
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Do any airborne work (i.e. - helicopter picks)
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Do any shoring
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Do blasting or work with explosives
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Operate a drone
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Work underground or in an area that could explode or collapse
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Have a contract or risk loss of $7 million or more
Subcontractors
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Will subcontractors be on site?
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Subcontractors:
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Scope:
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If yes, have we received their drug testing information, training, safety program, JSA?
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Will Subcontractors on site be required to open a locate ticket?
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Pre-Con Meeting Date
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Safety Meetings:
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Safety Milestones:
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Notes:
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Fuel Tank?
