L. Keeley Safety Assessment

• Project Title

• Job Number

• Client / Site

• Self perform project

• Subcontractor Name

• Conducted on

  Date

• Prepared by

• Location
  Address

• 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.

  Yes

  No

  N/A

Tools and Equipment

• Tools and equipment in good condition

  Safe

  At Risk

  N/A

• Machine guards/pinch points identified/protected

  Safe

  At Risk

  N/A

• Rigging/Lifting equipment in good condition and inspected

  Safe

  At Risk

  N/A

Electric tools and extension cords

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

• Electrical equipment connected properly and use of GFCI?

  Safe

  At Risk

  N/A

Heavy Equipment

• Daily inspection completed

  Safe

  At Risk

  N/A

• Fire extinguisher mounted and in good condition

  Safe

  At Risk

  N/A

• Seatbelt worn during operation

  Safe

  At Risk

  N/A

• Backup alarm operable?

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

• Any visible damage to equipment?

  Safe

  At Risk

  N/A

A. Personal Protective Equipment

• Hard Hats in use by all personnel

  Safe

  At Risk

  N/A

• Eye protection in use by all personnel

  Safe

  At Risk

  N/A

• 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

  Safe

  At Risk

  N/A

• Proper footwear

  Safe

  At Risk

  N/A

• Class II reflective vest/shirts worn by all employees

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

Hazardous Chemicals/Air Contaminants

• List of hazardous materials on job

  Safe

  At Risk

  N/A

• Material Safety Data Sheets

  Safe

  At Risk

  N/A

• Employees are familiar with program

  Safe

  At Risk

  N/A

• Proper containers in use with correct labels

  Safe

  At Risk

  N/A

General

• Safe access to work area

  Safe

  At Risk

  N/A

• Good housekeeping and material storage

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

Fall Protection (any At Risk = Auto Fail)

• Are ladders used for the manufacturers intended purpose?

  Safe

  At Risk

  N/A

• 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.

  Safe

  At Risk

  N/A

• Are employees protected from falls 6' or greater?

  Safe

  At Risk

  N/A

• Are employees properly wearing fall protection devices?

  Safe

  At Risk

  N/A

• Are employees properly tied off?

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

Trenching and Excavation (any At Risk = Auto Fail)

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

• Are ladder rungs 3' above the landing surface?

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

Paperwork and other Postings

• OSHA poster and state labor poster posted?

  Safe

  At Risk

  N/A

• Emergency phone number card

  Safe

  At Risk

  N/A

Safety behaviors, actions and conditions

• What safe actions/conditions were observed?

  List All

• How was safe behavior encouraged?

  List All

• What unsafe actions/conditions were observed?

  List All

• What was communicated to prevent reoccurrence of the unsafe acts/conditions that were observed?

  List All

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

• Add signature

  Sign