Information

  • Document No.

  • Operating Company

  • Project Name / Job Number

  • Conducted on

  • Prepared by

  • Location

Safety Program Administration

  • Appropriate Signage in Place

  • Safety Policy & Standard Operating Procedure Manual Onsite & Updated

  • Site Specific MSDS Binder Onsite

  • Federal, State, OSHA, Company,Required Postings Posted

  • Toolbox Safety Training Performed Weekly

  • Foreman Daily Safety Huddles Completed

  • JSA Completed Prior to Hazardous Tasks

  • Mentor Program is in Effect (Yellow Hard Hat)

  • Site Specific Emergency Action Plan

  • Applicable Permits Onsite (Trench/Excavation, Scaffold/Falsework, etc.,)

  • Weekly Safety Inspections Performed

  • Other;

First Aid

  • Trained Person(s) Onsite

  • First Aid Kit and Supplies Adequate in Size and Maintained

  • Eye Wash Station(s) in Place

  • Other;

Portable Generators

  • Guards in Place

  • Grounded System

  • GFCI Protection (Test Operation)

  • Damaged Outlets

  • Other;

Air Compressors

  • Belts and Pulleys Guarded

  • Pressure Gauge Working

  • Pressure Relief Valve Operational

  • Hose Connections Secured

  • Pressure Reduced at Operation

  • Hoses in Good Condition

  • Other;

Fire Extinguishers

  • Readily Accessible/Mounted

  • Proper Type and Size Available

  • Proper Maintenance/Tagged

  • Inspected Monthly/Annually

  • Employees Trained Annually on Usage

  • Other;

Flammable Liquids (Gasoline) / Chemical Handling

  • Stored in Approved Containers/Cabinets

  • Containers Properly Labeled (Identity, Hazard Warnings)

  • Spill Containment and Cleanup Supplies

  • Oxygen Cylinders Separated from Fuel Gas Cylinders or Combustible Materials (Min. 20' or 5' 1/2 Hr. Rated Fire Wall)

  • Fire Extinguisher Available Near Storage Areas w/in 25'

  • Hydrants are Clear and Access to Public Thoroughfare is Unobstructed

  • Signs Posted NO SMOKING "Flammable Materials"

  • Hazardous Chemicals in Secondary Containment, Proper Disposal

  • Storage Area Bermed for Spill (2 -1/2 Times Larger Than Tank)

  • Other;

Power Cords / Extension Cords / Electrical Hazards

  • Grounding Pin Present

  • Damaged Insulation Exposed Wiring

  • Plug Ends & Insulation Connected

  • Proper Gage (12/3 or Better)

  • All Circuits are GFCI Protected

  • Breaker Boxes and Switches Labled

  • Electrical Dangers Identified & Labeled

  • Cords Protected From Damage

  • Lock Out / Tag Out Procedures In Place

  • Other;

Powder Actuated Tools

  • Tool and Loads Properly Stored and Maintained

  • Certified/Trained Operator

  • Appropriate Signage Posted w/in 50'

  • Load Strips Properly Disposed of

  • Other;

Hand and Power Tools

  • All Mechanical Safeguards In Place as per Manufacturer & Cal OSHA Regulations (Zero Tolerance Item)

  • User Properly Trained

  • Tools Are in Good Condition

  • Correct Tool Being Used For The Job

  • Tools are Stored Neatly When Not In Use

  • Materials Properly Supported

  • Other;

Ladders and Stairways

  • Ladders Inspected and Maintained

  • Ladders Proper Length & Secured to Prevent Slipping, Sliding or Falling - Tied Off

  • Extension Ladders Extend 36" Above Landing

  • Extension Ladder Base Positioned 1/4 of the Vertical Distance

  • Area Around Base and Top of Ladder Clear and Unobstructed

  • Proper Maintenance and Storage

  • Stepladders Fully Opened

  • Job Made Ladders Constructed as Per Cal OSHA Regulations

  • Metal Ladders Not Being Used Around Electrical Hazards

  • Evidence of Unsafe Use of Ladders (Zero Tolerance Item)

  • Other;

Material Handling & Storage

  • Proper Lifting Techniques Being Used

  • Stacks on Firm Footing & Not Too High

  • Lay Down Areas Neat & Organized

  • Passage Ways are Clear

  • Other;

Personal Protective Equipment

  • Head Protection Hard Hat

  • Safety Glasses

  • Full Face Shield

  • Hearing Protection

  • Appropriate Hand Protection (Abrasion, Cut, Puncture, Chemical)

  • Foot Protection

  • Respiratory Protection

  • ANSI Class II or III High Visibility Garment (Vest, Shirt, or Jacket)

  • Other;

Fall Protection

  • Full Body Harness

  • Appropriate Connecting Device (Lanyard above 18', SRL below 18')

  • Appropriate Anchorage (5000 lb. Capacity)

  • Engineered Vertical or Horizontal Life Line

  • Guard Rails in Place and Secure, Top Rail 42"-45" Mid Rail at 1/2 the Distance

  • Controlled Access Zone Established

  • Warning Line Established

  • Competent Trained Person(s) Onsite

  • Employees Properly Trained

  • Equipment in Good Condition and Inspected Semi Annually

  • Rescue Plan In Place

  • All Personnel Protected Against Fall Height Greater Than 6' (Zero Tolerance Item)

  • Other;

Aerial Lifts

  • Equipped with Outriggers

  • Guard Rails in Good Condition

  • Full Body Harness and Fall Restraint in Use

  • Safety Chain Present and Connected

  • Employees Properly Trained

  • Employees Standing on Floor of Lift

  • Documented Daily Inspection Completed

  • Other;

Industrial Trucks (Tele-handler/Rough Terrain)

  • Roll Over Protective System (ROPS)

  • Documented Daily Inspection Performed

  • Back-up Alarm and Horn Operational

  • Fire Extinguisher

  • Operator Trained and Authorized to Use

  • Seatbelt Being Worn

  • Load Chart and Applicable Manuals on Lift

  • Lift being Operated in a Safe Manner

  • Other;

Cranes / Boom Trucks

  • Annual and Daily Inspections Complete

  • Fire Extinguisher in Cab & Inspected

  • Boom Angle Indicator and Load Charts Visible

  • Proper Hand Signals in Use & Posted

  • Swing Radius Barricaded

  • Rigging Inspected Prior to Use & in Good Condition, All Tags Legible & Attached

  • Rigging Properly Stored When Not In Use

  • Seat Belt Being Used

  • Qualified Rigger in Use

  • Qualified Signal Person in Use

  • Power Lines Deactivated, Removed or at a Minimum Safe Distance, Spotter in Use w/in 20'

  • Tag Line(s) in Use For Load Control

  • Equipment is Firmly Supported

  • OutRiggers In Use

  • Pre-Lift Meeting Conducted

  • Critical Lift Plan Reviewed

  • Operator Certified and Medical Card Current

  • Other;

General House Keeping

  • Orderly Storage of Material

  • Orderly Storage of Equipmen

  • Trash and Debris Picked Up

  • Adequate Supply of Trash Receptacles

  • Banding Material and Wire

  • Protruding nails Removed or Bent Over

  • Restrooms Clean and Supplies Adequate

  • Hand Wash Stations Supplied & Stocked

  • Dust Protection Observed

  • Lighting is Adequate

  • Other;

Heat Illness Prevention

  • Cool Drinking Water Supplied & Nearby

  • Disposable Cups & Trash Receptacles Provided

  • Adequate Shade Provided & Comfortable Seating

  • Employees Properly Trained

  • High Heat Requirements In Effect (95 degrees +)

  • Un-acclimatized Employees Monitored

  • Other;

Concrete Construction

  • Forms Properly Installed and Braced

  • Post "Laser In Use" Signage When in Use

  • Employees Using Lasers Properly Trained & Carrying Card

  • All Rebar, Round Form Stakes and Similar Protrusions Protected

  • Concrete Clean Out Area Designated and Set Up Properly

  • Mixing Transport has Adequate Runways and Traffic Controlled

  • Long Sleeved Shirts or Barrier Cream Used

  • Eye Protection, Hand Protection, Rubber Boots in Use

  • Communication Between Pump Hopper and Operator Maintained

  • Other;

Confined Space

  • Permit Completed

  • Verify Atmospheric Monitor Onsite & Calibrated w/in Last 30 Days

  • Bump Test Performed Prior to Entry

  • Continuos Monitoring Required and Documented every 30 Minutes

  • Ventilation of Space Adequate

  • Retrieval System in Place (Required for Entries over 5')

  • Pre-Task JSA Completed and Reviewed Prior to Entry

  • Rescue Procedures in Place & Reviewed Prior to Entry

  • Evidence of Work in a Non-Compliant Confined Space (Zero Tolerance Item)

  • Employees Involved Trained on Responsibilities (Supervisor, Attendant, Entrant)

  • Other;

Trenching and Excavation

  • Designated Competent Person Onsite

  • Documented Daily Inspection Performed

  • Proper Protective System for Soil Conditions in Place over 5'

  • Manufacturers Tabulated Data Available

  • Adjacent Structures Properly Supported

  • Adjacent Roads and Sidewalks Supported and Protected

  • Spoils Pile at Least 24" From Edge of Excavation

  • Excavation Adequately Barricaded

  • Equipment is Safe Distance from the Edge of Excavation

  • Extension Ladders Provided Where Needed - Within 25' of Workers

  • Equipment Ramps are Adequate

  • Evidence of Work In a Non-Compliant Excavation (Zero Tolerance Item)

  • Other;

Heavy Equipment and Vehicles

  • Operator Trained on Equipment Being Used

  • Seatbelt Worn at All Times

  • Inspection and Maintenance Logs Completed

  • Safety Devices Functioning Properly (Brakes, Lights, Mirrors, Horn, Etc.,)

  • Back-up Alarm Installed and Audible

  • Wheels Chocked on All Mobile Equipment When Standing Alone

  • Fire Extinguisher Present and Inspection Tag Current

  • Other;

Masonry (If Subcontractor Onsite)

  • Limited Access Zone Created Around Work Area, Signs Posted

  • Masonry Saws are Properly Equipped and Dust Containment Provided

  • Safe Hoisting Equipment In Use

  • Proper Scaffolding In Use (See Scaffolding)

  • Loads Properly Placed on Scaffolding

  • Walls over 8' Properly Braced Until Permanent Supports Are in Place

  • Other;

Scaffolding

  • Erection and Dismantling Must Be Supervised By a Qualified Person

  • Employees Trained on the Safe Use Of Scaffolding

  • Scaffold Components are in Good Condition

  • Scaffold Inspected Daily by Competent Person

  • Safe and Unobstructed Means of Access and Egress to All Scaffold Platforms

  • Work Area Must be Fully Planked & Planks Secured When Required

  • Workers Below Below Are Protected From Falling Objects - Toe Boards

  • Scaffold is Plumb and Square, Adequate Bracing in Place

  • Guard Railing and End Rails in Place (Top Rail 42" - 45" Mid Rail 1/2 the Distance Between

  • Scaffold Legs Nailed to Base Plate To Prevent Horizontal Movement

  • Scaffold Secured to Structure When Required

  • Scaffold Deck Free of Debris and Materials Are Secured

  • Stored and Work In Progress Materials Are Organized

  • Evidence Of Work Being Performed On Unsafe Scaffold System (Zero Tolerance Item)

  • Other;

Steel Erection (If Subcontractor Onsite)

  • Fall Protection Measures In Place

  • Temporary Periphery Cables at Each Floor Level

  • Tag Lines In Use To Control Load

  • Ladders, Stairs or Other Access Provided

  • Personal Fall Protection In Place as Per Cal OSHA Title 8 CCR 1710 (m)

  • Other;

Traffic Control

  • Cones / Delineators Used Around Work Site

  • Cones / Delineators Create Adequate Taper To Actual Work

  • Flaggers Are Trained & Wearing ANSI Class II or III High Visibility Garment

  • Workers Exposed To Vehicular Traffic Wearing ANSI Class II or III High Visibility Garment

  • Pre-Warning Signs In Place (Road Work Ahead, Flagger Ahead, Etc,.)

  • Sign Board(s) In Place To Warn of Lane Closure

  • Approved Traffic Plan In Place and Followed

  • Public Protected from Work

  • Spotter Used For Moving Of Equipment Near Or Through Traffic

  • Other;

Welding and Cutting

  • Equipment Is In Good Condition

  • Welders and Helpers Are Wearing Proper PPE

  • Adjacent Workers Protected By Screens or Shields

  • Electrical Equipment Is Grounded

  • All Cables Are Protected And In Good Condition

  • Fire Extinguisher Of Proper Type And Size In The Work Area

  • Flammable Materials Removed From Work Area Or Protected

  • Compressed Gas Cylinders Secured In Upright Position And Protective Caps In Place

  • Backflow Preventer On Leads From Oxygen and Acetylene Cylinders

  • Gas Lines Are Protected And In Good Condition

  • Hot Work Permit Completed When Required

  • Trained Fire Watch In Place (Min. Of 30 Minutes After Welding Task Completed)

  • Corrective Actions Taken / Summary

  • Project Supervision:

  • Safety Specialist:

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.