Title Page

  • Company Name

  • Project

  • Location
  • Foreman

  • Conducted on

  • Prepared by

Documentation

  • JHA/ Work Plan filled out

  • Weekly Safety Meeting/Toolbox talk

  • Permit required available

Personal Protective Equipment

  • Hard Hat worn

  • Eye/face protection used

  • Proper footwear worn

  • Gloves used

  • Safety Vest worn

  • Body Harness properly used

  • Respiratory protection used

Electrical/Hand tools/Power tools/Equipment

  • Proper tool in working conditions

  • Extension cords in working condition

  • GFCI used

  • Proper safety guard in place

  • Tool handles in working conditions

Fall Protection

  • Personal Fall Arrest System being used

  • Safety Harness/Lanyard/Anchor point used properly as required

  • Guardrail system set up as required

  • Warning lines set up as required

  • Safety Monitor following competent requirements

  • Safety Net set up as required

  • Floor openings covered, marked and secured

First aid, Fire and Hazcom

  • First aid kit available and fully stocked

  • Fire extinguishers available and in working conditions

  • SDS labels on containers legible

  • SDS available on site

  • Gas cylinders upright and secured

  • Fuel cans being used

Housekeeping and Sanitation

  • Drinking water and cups available

  • Restrooms clean and maintained

  • Trash and materials disposed off properly

  • Walkways/walk paths kept clear of hoses/ cords/debris

  • Housekeeping maintained

  • Work area proper access available

Ladder Safety

  • Ladder 3ft above and secured

  • Ladder condition and placement

Heavy equipment

  • Heavy equipment inspected

  • Load chart/angle indicator available

  • Power lines clearance kept

  • Back up alarm in working conditions

  • Seat belt being used

  • Swing radius barricaded

  • Operator following manufacturer's recommendations

  • Safe operations observed

Rigging procedures

  • Tag lines being used on all lift and hoisting maneuvers

  • Rigging equipment properly being stored when not in use

  • Personnel kept clear of swing radius/lifting zone/landing zone

  • Barricades being used to designate lifting area

  • Signalman/Flagger performing proper and safe operations

Excavation

  • Excavation properly protected

  • Excavation more than 5ft, protection system being used

  • Shoring, sloping, benching or trench box being used as protective system

  • Spoil bank kept at least 2ft from excavation

  • Ladder available

  • Competent person performing excavation requirements to protect employees

Scaffold

  • Competent person on site when erecting/dissembling scaffold

  • Mudsills places properly

  • Scaffold Inspection tag available

  • Base plates secured

  • Proper access and egress

  • Ladder secured and 3 feet above

  • Fully planked

  • Guardrails in place

  • Fixed to structure properly

  • Personal Fall arrest system used

  • Other

Additional observations

  • Other observations

  • Other observations

  • Other observations

Pictures attached

  • Attached media

Signature

  • Author

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.