Lindamood THA

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Project name/number

• Location
  Address

• Date

  Date

• Task description

• PPE

  Select Hard hat Safety glasses Safety vest Work boots-leather Gloves Hearing protection Fall protection-PFAS Face shield Dust mask Respirator Other

  • Hard hat
  • Safety glasses
  • Safety vest
  • Work boots-leather
  • Gloves
  • Hearing protection
  • Fall protection-PFAS
  • Face shield
  • Dust mask
  • Respirator
  • Other

• If other was selected, list the other PPE required.

• Hand hazards

  Select Cut Hazards Pinch points Material handling Hot/Cold hazard Crushing hazard Chemical hazard

  • Cut Hazards
  • Pinch points
  • Material handling
  • Hot/Cold hazard
  • Crushing hazard
  • Chemical hazard

• Special operations

  Select Ladders Scaffolding Boom/Scissor lift Excavations/Shoring Suspended loads-heavy equipment Suspended loads-cranes Confined space Elevators-dropping car & counterweights Elevators-debris chutes Utilities-verify "make-safe" Other

  • Ladders
  • Scaffolding
  • Boom/Scissor lift
  • Excavations/Shoring
  • Suspended loads-heavy equipment
  • Suspended loads-cranes
  • Confined space
  • Elevators-dropping car & counterweights
  • Elevators-debris chutes
  • Utilities-verify "make-safe"
  • Other

• If other, explain.

• Other work around you

  Select Moving equipment Material storage Delivery vehicles Overhead hazards Cranes/ hoisting Ground crews

  • Moving equipment
  • Material storage
  • Delivery vehicles
  • Overhead hazards
  • Cranes/ hoisting
  • Ground crews

• Environmental hazards

  Select Airborne particulates Electrical hazards Heat related illness Heavy lifting Noise Restricted access/exit Biological hazards Sharp objects

  • Airborne particulates
  • Electrical hazards
  • Heat related illness
  • Heavy lifting
  • Noise Restricted access/exit
  • Biological hazards
  • Sharp objects

• General requirements

  Select Post warning signs Barricades Ventilation Sufficient lighting Flammable material storage Other

  • Post warning signs
  • Barricades
  • Ventilation
  • Sufficient lighting
  • Flammable material storage
  • Other

• If other, explain.

• Housekeeping

  Select Debris/ Salvage materials properly sorted and stored Equipment and tools properly stored Walkways and working areas clean Hazardous materials disposed of properly Other

  • Debris/ Salvage materials properly sorted and stored
  • Equipment and tools properly stored
  • Walkways and working areas clean
  • Hazardous materials disposed of properly
  • Other

• If other, explain.

• Hazard communication/GHS

  Select SDS log available Discuss health hazards Discuss physical hazards First Aid kit

  • SDS log available
  • Discuss health hazards
  • Discuss physical hazards
  • First Aid kit

• Where is the First Aid kit located and who has First Aid training

• ALL ACCIDENTS AND INJURIES MUST BE REPORTED TO YOUR SUPERVISOR PROMPTLY. All reports of accidents and injuries reported to supervisors must be immediately passed up the chain of command.

• Hazards -bodily

  Select Cut potential Fall potential Slip/Trip potential Pinch points Lifting Twisting-while lifting Other

  • Cut potential
  • Fall potential
  • Slip/Trip potential
  • Pinch points
  • Lifting
  • Twisting-while lifting
  • Other

• If other, explain.

Task specific requirements

• List the steps required to complete today's task.

• List the potential hazards associated with each step above.

• List the recommended actions to address the hazards listed above.

• What are you going to achieve today?

• Is a Hot Work permit required for today's task? If so post it in the area where the Hot Work is being performed.

  Off

  On

• The workers assigned to this task were involved in completing this form.

• This form was completed on the job site.

Signatures

• Crew signatures

Crew signatures

• Sign your name here

  Sign

Supervisors signature

• Supervisors signature

  Sign