Title Page

  • Audit Title

  • Conducted on

  • Prepared by

  • Location
  • Competent Person

  • Opening Ticket Number

  • Permit Number

  • Weather

1.0- Workplace

  • 1.1.-Code 753 (Mark Outs)

  • 1.2- Inspector

  • 1.3- Competent Person

2.0- Administrative

  • 2.1- Documentation of Job Briefing

  • 2.2- Certification, Certificates of Fitness, & Training Cards

  • 2.3- Air monitor in use, equipment calibrated & current

  • 2.4- Air monitor log on-site

  • 2.5- HASP on-site & Current

  • 2.6- Permits posted & visible

  • 2.7- Complete job package on-site

  • 2.8- Noise Mitigation Plan posted when required

  • 2.9- Con Edison's rule book for MUTCD on-site

  • 2.10- First Aid Kit on-site

  • 2.11- Spill Kit on-site

  • 2.12- Fire extinguisher visible & immediately available on-site

  • 2.13- Complete contact list

  • 2.14- Local hospital information

  • 2.15- Safety Data Sheet on-site (SDS's)

  • 2.16- CEHSP 17.02 Gas Enclosed Space Entry Procedures

  • 2.17- CEHSP 17.01 Electrical Enclosed Entry Procedures

  • 2.18- CEHSP 13.00 Excavation Procedures

  • 2.19- Current RWLB Matrix Post

  • 2.20- HASP Acknowledgement form on-site & signed

Work Area Protection

  • 3.1- Flagger posted with advanced warning signs & flags

  • 3.2- Crash worthy barricades in use, complete & in compliance

  • 3.3- Stanchions & cones connected where required

  • 3.4- MUTCD set-up signs in use when required

  • 3.5- Arrow board operating properly & in use if applicable

  • 3.6- Flag trees in use if required

  • 3.7- Pedestrians provided with a safe & clear travel

  • 3.8- Plates; pinned, ramped, flush, & skid proof where required

  • 3.9 Manhole guardrail in use when work is in progress in such areas

  • 3.10- Slings & chains in good condition

  • 3.11- Rubber electrical gloves dated within expiration date

  • 3.12- Proper PPE in use when required

  • 3.13- Vehicle's engines turned off (idling regulations)

  • 3.14- Seat belts intact & in good condition

  • 3.15- Wheel Chocks in use when truck is in standby

  • 3.16- Hydrants & bus stops clear

  • 3.17- All tools in good shape

  • 3.18- Adequate set-up

  • 3.19- Housekeeping

4.0 Excavation

  • 4.1- Spoils & equipment 2' away from excavation

  • 4.2- Gas monitoring when required

  • 4.3- Ladders used at 4' depth or greater

  • 4.4- Ladders in place for every 25' of lateral travel

  • 4.5- Shoring / Sheeting when required

  • 4.6- Daily Excavation inspection conducted

Sign off

  • On-site Representative

  • Auditors 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.