Is a lockout required?
Working on/near live electrical?
Working from heights?
Other activities in area :
Hot/cold surfaces, materials
Controls used :
Slip - Trip
Manual Lifting KG
Work Over Head
System Under Pressure
Are you working alone?
Contact Person :
Phone Number :
Is the equipment in good condition?
Do you have the proper rigging?
Have you done an inspection of the surrounding area?
Are the hand tools in good condition?
Is the scaffold in good condition?
Is the ladder in good condition?
Is the ladder secure?
Do I have the right ladder for the job?
Fixed Barricades (used if tape has potential to become damaged)
(Tape) Danger (used to keep people out)
(Tape) Caution (used to alert people to hazards)
Barricade Tags (required with barricades)
Are signs of warning required?
Are holes covered?
Are handrails in good condition?
Is a fire extinguisher required?
Safety shower # :
Eyewash # :
Muster point :
Closest Door # :
ERT contact (confined space) :