Job Safety Audit Form

• Conducted on

  Date

• Prepared by

• Location
  Address

• Date:

  Date

Unit:

• Equipment No

• Audit Performed By:

• Permit Issuer:

• Company (Audited):

• Job Rep:

GENERAL – Section A

As a Section NA

• A1 Permit on site and properly filled out?

  Yes

  No

  N/A

• A2 Permit matches job?

  Yes

  No

  N/A

• A3 Field check performed/walked out by a Job Representative?

  Yes

  No

  N/A

• A4 Workers understand the job scope? (ask sampling of workers)

  Yes

  No

  N/A

• A5 Proper PPE worn?

  Yes

  No

  N/A

• A6 Personnel wearing security badge?

  Yes

  No

  N/A

• Section Grade (no = 6-point deduction each no)

CONFINED SPACE – Section B

• B1Space properly isolated?

  Yes

  No

  N/A

• B2 Rescue Pre Plan in place?

  Yes

  No

  N/A

• B3 Atmospheric monitoring in place?

  Yes

  No

  N/A

• B4 Communication equipment in place?

  Yes

  No

  N/A

• B5 Ventilation in place?

  Yes

  No

  N/A

• B6 Confined Space sign in place?

  Yes

  No

  N/A

• B7 Attendant in place and understands their responsibilities?

  Yes

  No

  N/A

• B8 Entry supervisor pre-entry inspection completed?

  Yes

  No

  N/A

• Section Grade (no = 8 point deduction per each no)

EXCAVATION – Section C

• C1 Shoring or sloping in place?

  Yes

  No

  N/A

• C2 Proper barricades?

  Yes

  No

  N/A

• C3 Means of egress in place?

  Yes

  No

  N/A

• C4 Excavation permit completed?

  Yes

  No

  N/A

• Section Grade no=4 point deduction per each no)

LOTO – Section D

As a Section NA

• D1 Permit LOTO section completed?

  Yes

  No

  N/A

• D2 EIL Complete?

  Yes

  No

  N/A

• D3 Master Tag Roster Completed?

  Yes

  No

  N/A

• D4 Authorized personnel have signed in/out on the master tag roster?

  Yes

  No

  N/A

• Section Grade (no=4 point deduction per no)

HOT WORK – Section E

• E1 Fire Watch in place and understands their responsibilities?

  Yes

  No

  N/A

• E2 Atmospheric monitoring in place?

  Yes

  No

  N/A

• E3 Fire Extinguisher In Place

  Yes

  No

  N/A

• E4 Area clear of combustible material (35 feet)?

  Yes

  No

  N/A

ELECTRICAL – Section F

As a Section NA

• F1 Power tools in good condition?

  Yes

  No

  N/A

• F2 GFCI in use?

  Yes

  No

  N/A

• F3 Clearances for overhead power lines?

  Yes

  No

  N/A

• Section Grade (no=3 point deduction per no)

ELEVATED WORK – Section G

• G1 Scaffold inspection up to date?

  Yes

  No

  N/A

• G2 Scaffold has proper handrails, midrails, toe boards, etc?

  Yes

  No

  N/A

• G3 Pre-Use scaffold inspection complete?

  Yes

  No

  N/A

• G4 Harness, lanyard worn and tied off?

  Yes

  No

  N/A

• G5 Proper ladder use?

  Yes

  No

  N/A

• G6 Ladder safe for use?

  Yes

  No

  N/A

• Section Grade (no=6 point deduction per no)

BARRICADES – Section H

• H1 Barricades installed (especially for overhead work)?

  Yes

  No

  N/A

• H2 Barricade tags in place?

  Yes

  No

  N/A

• Section Grade (no = 2 point deduction per no)

CRITICAL LIFT – Section I

• I1 Critical Lift Plan in place?

  Yes

  No

  N/A

• I2 Area barricaded?

  Yes

  No

  N/A

• I3 Spotter in use?

  Yes

  No

  N/A

VEHICLE SAFETY – Section J

• J1 Seat belt worn while operating equipment?

  Yes

  No

  N/A

• J2 Spotter used while operating equipment within the unit?

  Yes

  No

  N/A

• J3 Safe driving practiced?

  Yes

  No

  N/A

SAFETY EQUIPMENT – Section K

• K2 Fire extinguisher current inspection?

  Yes

  No

  N/A

• K3 Fire extinguisher fully charged?

  Yes

  No

  N/A

• K4 Intercom available and working?

  Yes

  No

  N/A

• K5 Safety shower / eye wash station working?

  Yes

  No

  N/A

• Section Grade (no = 4 point deduction per no)

• Describe any deficiencies:

Corrective actions:

AUDIT GRADE =

• Department Manager/On Duty Supervisor:

  Sign

• Print Name:

  Sign

• TOTAL AUDIT GRADE