Title Page

  • Job Name

  • Client / Site

  • Prepared by

  • Personnel

  • Conducted on

  • Location

Fall Protection

  • Fall Protection

  • Details:

  • Picture(s):

  • Fall protection present at 6' or above?

  • Rescue plan present and reviewed?

  • Guardrails at 42"/21" +/- 3"?

  • Have users been trained and documented in fall protection?

  • Has fall protection equipment been inspected prior to use? (Safety Harness, SRL, Anchor Points)

  • Are floor and wall openings protected, covered, and marked? Are covers adequate, secured, and labelled?

  • Is protection present for changes in elevation?

Ladders/Stairs

  • Ladders/Stairs

  • Details:

  • Picture(s):

  • Is ladder free of defects?

  • Is ladder being used properly?

  • Is ladder secured?

  • Is extension ladder used on a 4:1 pitch?

  • Does ladder extend 3' or more above landing?

  • Is ladder a safe work distance from hazard?

  • Have slip/trip exposures on ladder been eliminated?

  • Are access/egress areas free of debris/materials?

Excavations

  • Excavations

  • Add media

  • One-Call System used?

  • Surface traffic exposure?

  • Are daily inspections documented?

  • Are excavations > 20' engineered?

  • If water entering excavation, is it adequately controlled?

  • Is excavation >5' deep properly sloped, benched or shored?

  • Is a ladder present in excavation over 4' deep and withing 25' of workers?

  • Spoils >2' from edge?

  • Surface encumbrances present within 2' off edge?

  • Perimeter properly protected?

Confined Space

  • Confined Space

  • Add media

  • Are atmospheric conditions being monitored?

  • Is Permit required?

  • Are secured/sinage posted?

  • Are rescue plans, emergency numbers, map readily available?

  • Is training documentation readily available?

  • Are regular periodic inspections, including monitoring, taking place?

  • Is ventilation adequate?

  • Is harness and extraction equipment inspected and in proper working condition?

  • Are electrical and/or fire hazards present?

  • Is respiratory equipment in proper working condition?

  • Is entry supervisor/monitor present and properly trained?

Motorized Equipment

  • Motorized Equipment

  • Add media

  • Is operator working safely?

  • Is machine operating at least 10' away from overhead power lines?

  • Is proper operator protection in place (ROPS, Cage, Screen, etc.)?

  • Are seat belts being used?

  • Does backup alarm function properly?

  • Is fire extinguisher present with current inspection?

  • Is flag man required/present?

  • Is glass free of obstructions?

  • Does horn function properly?

  • Is weekly equipment inspection form completed?

Electrical

  • Electrical

  • Add media

  • Is electrical equipment properly grounded?

  • Are GFCI's being utilized?

  • Are appropriate cords being used and in good condition? (3-wire/12 gauge type cords-no exposed wires, cuts in rubber-ground pin)

  • Are cords protected from traffic?

  • Are energized parts and equipment protected?

  • Are LOTO procedures in use?

  • Is signage present warning of electrocution hazards? (Where applicable)

Hand & Power Tools

  • Hand & Power Tools

  • Add media

  • Proper tool for the job?

  • Tool in good condition? Ground prong in place? GFCI's in use?

  • Anti-whip attached to pressurized lines?

  • Auto shut-off/ safety switches operational?

  • Strain relief functioning properly?

  • Proper PPE? (Face shield, chaps, gloves, etc.)

Manual Material Handling

  • Manual Material Handling

  • Add media

  • Proper lifting technique? (Lifting in "power zone", no twisting, no over reaching)

  • No manual lift over 50 lbs

  • Lifts over 50 lbs get aid or assistance

  • Use of mechanical aid? (if applicable)

  • Clear and planned path?

PPE

  • Add media

  • Hard hats

  • Safety glasses (goggles where applicable)

  • Face shields

  • Hearing protection

  • Respiratory Protection

  • Appropriate clothing for the task (hi-vis, chaps, fire retardant, etc.)

  • Gloves

  • Work boots

  • Visitor PPE available?

Fire Protection

  • Fire Protection

  • Add media

  • Extinguishers charged and inspections current?

  • Extinguishers at least 25' from fuel station, not more than 75'?

  • Temporary fuel station properly protected (sings, barricades, ground pin, locks, etc)?

  • Flammables stored properly (vented, labelled, containers 20' away from other unlike flammables)?

  • Flammables stored away from structures?

  • Clear access for emergency vehicles, hydrants?

Housekeeping

  • Housekeeping

  • Add media

  • Is trailer access/egress hazard free?

  • Are sanitary facilities available, adequate, and clean?

  • Is an adequate supply of drinking water available?

  • Are slip, trip, and fall hazards present in or around work areas?

  • Is material storage adequate and utilized properly?

  • Is trash collected in protected containers?

Medical/Emergency

  • Medical/Emergency

  • Add media

  • Is there an individual certified in first aid/CPR onsite?

  • Is there a first aid kit available onsite?

  • Is eyewash available?

  • Are emergency/safety team/hotline numbers posted?

  • Is a map to medical facility available/posted?

  • Is a map to medical facility available/posted?

HAZCOM

  • HAZCOM

  • Add media

  • Are employees trained?

  • Site Specific SDS available?

  • Copy of program readily available?

  • Containers properly labelled and inventory listed?

Environmental

  • Environmental

  • Add media

  • Are airborne contaminants properly controlled/eliminated?

  • Is HazMat storage, use, and disposal adequate/appropriate?

  • Is spill containment adequate/appropriate?

  • Is concrete cut wet and/or vacuumed?

  • Is nuisance dust controlled/eliminated?

Site/Public Protection

  • Site/Public Protection

  • Add media

  • Are excavations properly protected?

  • Is falling object/overhead protection in place?

  • Are perimeter fences installed?

  • Is impalement protection in place? (Re-bar caps)

  • Are barricades installed properly?

  • Is adequate lighting available?

  • Is public protection signage necessary/present?

  • Is traffic control plan in place?

  • Is street closure properly identified?

Administration

  • Administration

  • Add media

  • Is a properly trained supervisor on site?

  • OSHA posters posted?

  • State/Fed. posters posted in English/Spanish?

  • Is an IX safety manual readily available?

  • Is trench box tabulated data readily available?

  • Have IX orientations been conducted/completed?

  • Has a JSA been submitted for each trade/task?

  • Are changing conditions being noted on JSA and communicated as needed?

  • Are Pre-con meetings documented?

  • Is there documentation of corrective actions taken since last audit?

  • Are toolbox talks being conducted and recorded weekly?

  • Silica Plan displayed in trailer?

Welding/Cutting

  • Welding/Cutting

  • Add media

  • Fire extinguisher present; properly charged, inspected?

  • Is welding flash protection available?

  • Are flash arresters present?

  • Are cylinders 20' apart or separated by burn barrier?

  • Are gauges working and adjusted properly?

  • Is burn permit in use and properly filled out?

  • Are cylinders upright, capped, and properly secured?

  • Are torch hoses in good condition?

  • Is proper PPE in use (FR clothing, gloves, burning shield, safety glasses)?

  • Is welding machine properly ventilated?

  • Are welding leads in good condition?

Aerial Lifts

  • Aerial Lifts?

  • Add media

  • Annual inspection current?

  • Are operator training records readily available including fall protection training?

  • Are PFAS (Personal Fall Arrest Systems) in use during operation?

  • Is gate or chain secured?

  • Is lift operating on stable surface?

  • Is operating surface free of holes, sudden changes in elevation?

  • Are safe work distances addressed and maintained?

  • Is equipment loaded properly (not to exceed manufacturers weight limit including operator, tools, and equipment)?

Cranes & Hoisting Equipment

  • Cranes & Hoisting Equipment?

  • Add media

  • Annual inspection current?

  • Are daily inspections performed and current?

  • Are operator, signaler/rigger training records readily accessible?

  • Is crane properly supported and level?

  • Are safe work distances from power lines being adhered to?

  • Fire extinguisher present; properly charged, inspected?

  • Is a lift plan, operator certs, and evaluation readily available?

  • Is the proper load chart posted?

  • Are outriggers properly extended, supported, cribbed?

  • Are loads properly rigged by a trained, qualified rigger?

  • Has the weight of the load been verified?

  • Has rigging been properly rated and inspected?

  • Are safety latches present and being used?

  • Has swing radius been properly barricaded?

  • Are tag lines being used properly?

  • Are effective means of communication in use?

  • Is boom angle indicator in place and working properly?

  • Is operator's manual present in crane?

  • Rigging?

  • Add media

  • Are loads properly rigged by a trained, qualified rigger?

  • Has rigging been properly rated and inspected?

  • Are safety latches present and being used?

  • Are tag lines being used properly?

Scaffolds

  • Scaffolds?

  • Add media

  • Are scaffolds inspected daily and documented?

  • Are scaffold user training records readily available?

  • Are all appropriate guard rails in place?

  • Are all wheels locked?

  • Are compatible components used?

  • Are outriggers necessary and installed properly?

  • Are bracing and pins placed properly?

  • Is scaffold properly secured to structure?

  • Is proper access to platforms present?

  • Is scaffold properly guyed at 4:1 height to base ratio?

  • Are materials being loaded properly?

  • Have safe work distances been addressed and maintained?

  • Are sills, plates, and jacks properly installed?

  • Is work surface in safe condition?

Safety Equipment/Supplies

  • Tripod

  • Winch

  • 4 Gas Meter

  • SRL(s)

  • Beam Clamp(s)

  • Life Lines

  • Misc.

Conclusion

  • I agree to address and abate the above issues prior to

  • Name

  • Signature

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.