Title Page
-
Conducted on
-
Prepared by
-
Project
-
Foreman
-
Select date
Employees Wearing PPE
-
Hard hats worn correctly.
-
Safety glasses, side shields, face shields ANSI approved.
-
Safety-toe boots.
-
Respiratory protection.
-
Gloves.
-
Hearing protection.
-
High visibility clothing.
Safety Preparation
-
Emergency action plan card distributed.
-
Emergency phone #’s posted in orientation.
-
Checklist for new employees completed.
Borrow Site
-
Fuel containers free of debris.
-
Spill kits on location.
-
Silt fence around stockpiles.
-
Emergency phone #’s posted.
-
Berms built at least half the height of the tallest truck tire on site.
-
Entrance- Any dirt track out.
-
Dust control needed.
-
Traffic signs needed (Trucks Turning, etc.)
-
Overhead power signs needed.
-
Locked gates on entrances.
Excavation & Trenching Information
-
If trench is over 5 feet, what protective system(s) are in use.
- Trench Box
- Benching
- Shoring
- Sloping
- N/A
- No safety measures in place.
-
Ladder & Ramp located in 4 feet and deeper trenches.
-
Ladder extends 3 feet above trench.
-
Two exits for trenches over 25 feet long.
-
Spoil pile is 2 feet or more away from edge.
-
Barricades in place around excavations.
Housekeeping
-
Bathrooms on site
-
Trash container provided.
-
Walking/Working areas clear of debris.
-
Adequate lighting provided.
-
Storage areas are clean and organized.
-
Spill kits on site.
Inspections as Required
-
Hand/Power Tools.
-
Fire extinguishers.
-
Vehicles & Equipment.
-
Ladders.
-
Fall Protection.
-
Rigging.
-
Excavation.
-
Other.
Site Specific Reminders
-
Wash hands, face, hair, & self daily.
-
Keep windows closed as much as possible.
-
Check and clean cab filters often.
-
Be aware of cross contamination (finger to eye or nose, etc.)
-
Keep dirty clothes separate & wash thoroughly.
-
Other notes and observations.
-
Supervisor Signature
-
Safety Director Signature
