Information
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Job Title
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Conducted on
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Location
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Temperature
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Precipitation
General/Housekeeping
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Slip/Trip Hazards Abated
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Aisleways Clear
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Pinch Points Eliminated
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Loose Material/Debris Removed
PPE Required
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Eye Protection
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Type
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Head Protection
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Type
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Hand Protection
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Type
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Fall Protection
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Type
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Fire Retardant Clothing (FRC)
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Type
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Face Protection
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Type
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Hearing Protection
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Type
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Foot Protection
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Type
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Respiratory Protection
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Type
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Other
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Type
Tools
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Proper Tool For Job
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Visual Inspection
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In Good Condition
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Other
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Type
Emergency Equipment
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Fire Extinguisher
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Evacuation Route
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Phone Numbers
Access/Overhead Work
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Scaffolds Insp./Tagged
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Handrails/Toeboards
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Ladders Approved
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Ext. Ladders Tied Off
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Overhead Work Signs
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Barricades Utilized
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Holes In Decks Covered
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Climbing Hazards Abated
Confined Space
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Authorized Entrants
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Authorized Attendants
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Communication w/ Entrants
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Communication w/ Rescue
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Confined Space Gas Tests
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Completed Entry Permit
Heavy Equipment
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All Equipment Inspections Current
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Weight of Load (lbs)
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Lifting Radius Verified
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Load Chart Verified
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Chain Fall Cap. Adequate
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Come Along Cap. Adequate
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Rigging Inspected
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Correct Type of Rigging
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Softeners Used
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Electric Line Clearance
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Tag Lines Used
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All Operators Qualified
Electrical
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LO/TO Complete
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GFCI Used
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Equipment Grounded
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Cords Inspected
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Cords Protected
Other Verifications
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Pre-Shift Job Instructions
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Work Scope Covered w/ Crew
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MSDS Location
Verification of Review
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Have Lines Been Marked
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LO/TO Completed
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Were All Permits Reviewed
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Hot Work Permit #
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Confined Space Permit #
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General Work Permit #
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Wind Speed
Work Area
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Are Hazards Associated with the Following Conditions Eliminated?
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Dusts
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Electrical Shock
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Heat Stress
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Heavy Objects
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Surface Temperature
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Inadequate Lighting
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Initial Opening
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High Noise Level
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Poor Access/Egress
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Poor Housekeeping
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Sharp Objects
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Other
Bodily Hazards
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Are Hazards Associated with the Following Conditions Eliminated?
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Falls
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Pinch Points
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Slips/Trips
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Manual Lifting
Chemical
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Are Hazards Associated with the Following Conditions Eliminated?
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Burns
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Flammability
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Absorption
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Ingestion
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Inhalation
Other Commentary
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Remember to Concentrate on Preventing Eye, Hand, and Back Injuries
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List Job Steps
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List of Hazards Present
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Corrective Action/Controls
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Equipment Needed for the Job
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Comments
Employee Signatures
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