Information

  • Document No.

  • Conducted on

  • Prepared by

  • Company

  • Location

LIFE CRITICAL TOTAL

  • Work Platforms & Scaffolding

  • Corrective Action Due Date:

  • Fire Prevention & Protection

  • Corrective Action Due Date:

  • Electrical

  • Corrective Action Due Date:

  • Confined Spaces

  • Corrective Action Due Date:

  • Plant & Equipment

  • Corrective Action Due Date:

  • Working at Height

  • Corrective Action Due Date:

  • Lifting Operations

  • Corrective Action Due Date:

  • Excavations & Trenching

  • Corrective Action Due Date

  • Add media

HEALTH & WELFARE TOTAL

  • Work Area

  • Corrective Action Due Date:

  • Trash Containers/Disposal

  • Corrective Action Due Date:

  • Rest Areas

  • Corrective Action Due Date:

  • Drinking Water

  • Corrective Action Due Date:

  • Toilets/Washing Facilities

  • Corrective Action Due Date:

  • First Aiders/First Aid Kits

  • Corrective Action Due Date:

  • Add media

WORK ENVIRONMENT TOTAL

  • Heat Stress

  • Corrective Action Due Date:

  • Noise

  • Corrective Action Due Date:

  • Illumination

  • Corrective Action Due Date:

  • Dust Suppression/Control

  • Corrective Action Due Date:

  • Object/Line of Fire Hazards

  • Corrective Action Due Date:

  • Access/Egress

  • Corrective Action Due Date:

  • Traffic Management/Barricades

  • Corrective Action Due Date:

  • Safety & Road Signage

  • Corrective Action Due Date:

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EQUIPMENT & PROCEDURES TOTAL

  • Personal Protective Equipment

  • Corrective Action Due Date:

  • Hand & Power Tools

  • Corrective Action Due Date:

  • Management & Supervision

  • Corrective Action Due Date:

  • COSHH

  • Corrective Action Due Date:

  • People (Behaviors)

  • Corrective Action Due Date:

  • Method Statements/Risk Assessments

  • Corrective Action Due Date:

  • Permit to Work

  • Corrective Action Due Date:

  • Take 5 Card

  • Corrective Action Due Date

  • Add media

OTHER TOTAL

  • Observation #1:

  • Corrective Action Due Date:

  • Observation #2:

  • Corrective Action Due Date:

  • Observation #3:

  • Corrective Action Due Date:

  • Add media

GOOD PRACTICE PHOTOS

  • Add media

  • Add media

  • Add media

  • Add media

  • Add media

REPORT SUMMARY

  • Corrective Action Report (CAR) Issued?

  • Reason for CAR:

  • Non-Compliance Report Issued?

  • Reason for Non-Compliance Report:

  • Was there a Work Stoppage?

  • Reason for Work Stoppage:

  • Kier Safety Representative Signature:

  • Kier Construction Representative Signature:

  • Other Comments

VERIFICATION & CLOSEOUT:

  • Kier Verification Signature/Date/Comments:

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