Information

  • Project Title

  • Document No.

  • Client / Site

  • Self perform project

  • Subcontractor Name

  • Conducted on

  • Prepared by

  • Location
  • Site Manager/Superintendent

Pre Task and/or JSA (At Risk = Auto Fail)

  • Was a Pre task or JSA completed for the task conducted and reviewed with all employees.

Tools and Equipment

  • Tools and equipment in good condition

  • Machine guards/pinch points identified/protected

  • Rigging/Lifting equipment in good condition and inspected

Electric tools and extension cords

  • Are electric tools and extension cords double insulated and has no visible signs of damage?

  • Do electric tools and extension cords have a grounding conductor?

  • Electrical equipment connected properly and use of GFCI?

Heavy Equipment

  • Daily inspection completed

  • Fire extinguisher mounted and in good condition

  • Seatbelt worn during operation

  • Backup alarm operable?

  • Ground guide/spotter being used? Performing task correctly?

  • Any visible damage to equipment?

A. Personal Protective Equipment

  • Hard Hats in use by all personnel

  • Eye protection in use by all personnel

  • Hearing protection in use. Rule of thumb: If standing 5' or more apart and you have to raise your voice to communicate hearing protection is needed

  • Proper footwear

  • Class II reflective vest/shirts worn by all employees

  • Are employees wearing gloves while performing tasks that could injure their hands?

Hazardous Chemicals/Air Contaminants

  • List of hazardous materials on job

  • Material Safety Data Sheets

  • Employees are familiar with program

  • Proper containers in use with correct labels

General

  • Safe access to work area

  • Good housekeeping and material storage

  • Is the work area properly demarcated/blocked off to prevent injury/entry of the public?

  • Fire extinguisher; Good condition; current inspection tag; within 50'

  • First Aid kit/ eye wash and CPR/First Aid trained personnel available

  • Trucks; safe/good condition; DOT regulation compliance?

  • Are ladders used for the manufacturers intended purpose?

  • Are ladders properly secured, three feet above landing surface, and the base is placed 1/4 of the working length from wall or other vertical surface.

Fall Protection (any At Risk = Auto Fail)

  • Are employees protected from falls 6' or greater?

  • Are employees properly wearing fall protection devices?

  • Are employees properly tied off?

  • Fall protection equipment in proper working order and inspections completed?

  • Are employees using fall protection properly while operating a mobile platform?

Trenching and Excavation (any At Risk = Auto Fail)

  • Has water accumulated, or is water accumulating, in the excavation/trench?

  • Are soil piles, tools, and equipment stored 2' or more from the edge of the excavation?

  • Are ladder rungs 3' above the landing surface?

  • Is access and egress provided every 25' of lateral movement when the excavation/trench reaches 4' in depth?

  • Is the excavation/trench properly protected at 5' in depth?

  • Fall protection in place when excavation/trench reaches 6' in depth?

  • Is the excavation/trench 20' or more in depth? If yes, is the protective system designed by a Professional Engineer?

Paperwork and other Postings

  • OSHA poster and state labor poster posted?

  • Emergency phone number card

Safety behaviors, actions and conditions

  • Rank the crews attitude towards safety (1-10)

  • Add signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.