Information

  • Supervisor

  • Foreman

  • Date

  • Job No.

  • Location
  • Prepared by

Daily Safety & Pre-Task Planning

Daily Safety & Pre-Task Planning

  • Are Daily Safety & Pre-Task Planning forms being completed?

  • Is the work being done matching the form?

  • Why is not being completed?

  • Daily huddle completed?

  • Employee Comments

  • Comments
  • Name

  • Comments

Emergency

Emergency Plan

  • Do employees know of the emergency plan?

  • 911 Confirmation

  • Clinic/Hospital Location

New Employees

  • Jobsite Orientation

  • Integration

  • New Employee Concerns

  • Concerns
  • Name

  • Concern

New Employee

New Employee

  • Have you completed job site orientation?

  • Are you being welcomed in/how are you fitting in?

  • Do you have any concerns?

New Employee

  • Have you completed job site orientation?

  • Are you being welcomed in/how are you fitting in?

  • Do you have any concerns?

New Employee

  • Have you completed job site orientation?

  • Are you being welcomed in/how are you fitting in?

  • Do you have any concerns?

TPR

TPR (Open Ended Questions)

  • Issues and Concerns?

  • Comment
  • Describe

Machinery

  • Lubricated?

  • Clean?

  • Seat belt?

  • Safety equipment?

  • Any issues with One Call or Operator Care?

  • Explain

Locates

Overhead

  • Power Lines

  • How far away (in ft.)?

  • Phone Lines?

Underground

  • Power Lines

  • How far away (in ft.)?

  • Phone Lines?

  • Fiber-optics?

  • Gas lines?

  • Water Lines?

  • Sewer Lines?

Traffic Control

  • Designated employee parking?

  • Picture

  • Suggestions for parking spots

  • Picture

  • Pedestrian Traffic Areas designated and guarded?

  • Picture

  • Haul Routes and/or Traffic Pattern in place?

  • Work zone signing/traffic control manual in place?

Trench Safety

  • Type of Soil Present

Which types? (check all that apply)

  • A

  • B

  • C

  • Is the trench safe?

  • Picture

  • Ladders within 25ft of employees?

  • Are employees aware of the rescue plan?

Chains and Slings

  • Chains and Slings

  • Equipment
  • What is the condition of the chains/slings?

  • Photos

  • Have the chains/slings been inspected and certified within the last year?

  • Date of last inspection

Employees

  • Are employees operating within the danger zone/swing zone of equipment?

  • Are employees aware of danger zone/swing zone?

Cranes

Crane

  • Is there a Certified Crane Operator (CCO)?

  • Load chart and lift chart located in the crane?

  • Condition of the crane?

  • Are employees working underneath crane loads?

  • Picture

Pile Driver

  • Is the driver/hammer in good condition?

  • Are the manufacturing plates attached and inspected?

  • Date of Last Inspection

Power/Hand Tools

Tool

    Tool
  • Name of Tool

  • Proper Guarding on Tool?

  • Exterior Damage?

  • Describe

  • Picture

  • Are cord(s) cut, frayed, damaged?

  • Describe

  • Picture

PPE

  • Proper PPE worn? (select all that apply)

Fall Protection

Lifts (Scissors, Aerial, Boom)

    Lift
  • Lift #

  • Daily inspection complete?

  • Used correctly?

  • Damage?

  • Photo

  • Describe

Ladder

    Lift
  • Daily inspection complete?

  • Used correctly?

  • Damage?

  • Photo

  • Describe

  • Tied off?

  • Temporary or Permanent?

Guardrail

    Guardrail
  • Location
  • Damage?

  • Photo

  • Top rail, mid rail, and toe kick?

  • Top

  • Mid

  • Toeboard

Body Harness and Lanyards

    Harness
  • Serial #

  • Daily inspection?

  • Damage?

  • Photo

  • Lanyard
  • Serial #

  • Daily inspection?

  • Damage?

  • Photo

  • Harness
  • Daily inspection?

  • Damage?

  • Photo

  • Harness
  • Daily inspection?

  • Damage?

  • Photo

  • Lift
  • Lift #

  • Daily inspection complete?

  • Used correctly?

  • Damage?

  • Photo

  • Describe

PPE

Are employees wearing....?

  • Safety Vests?

  • Are the vests in good condition (clean, reflective material visible, etc.)?

  • Safety glasses?

  • If grinding/cutting, are face shields also being worn?

  • Hearing protection (if required)?

  • Hard hats?

  • Are hard hats free from nicks, gouges, and is suspension inside hard hat adjusted properly?

  • Sun protection? (sunscreen, UV protective clothing)?

  • Seat belts on equipment being worn?

  • Fall protection (if required)?

Chain Saw Safety (if applicable)

  • Chaps being worn and fitted properly?

  • Hard hat?

  • Face shield and safety glasses being worn?

  • Hearing protection?

  • Gloves being worn?

Erosion Control

  • Erosion control measures in place?

  • Following SWPPP?

Cell Phone usage

  • Do employees have cell phones on their person?

  • Are cell phones being used during work hours?

Previous Job Site Inspection

  • Date of Last Job Site Inspection

  • Name of Supervisor

Finalization

  • Executive Safety Committee Member

  • Select date

  • Add signature

  • Supervisor

  • Select date

  • Received copy?

  • Add signature

Control of Hazardous Energy

  • Lock-out/tag-out procedures in place?

  • Add media

Wiring, Hoses, Jacks, Vessels

    Problems
  • Describe any problems, if applicable

  • Photos, if applicable

Fire Safety

Extinguishers

    Extinguisher
  • Serial #

  • Date of last inspection

  • Are extinguishers clearly marked?

  • Are extinguishers free from material in front and around of them?

  • Do employees know how to use extinguishers? (P.A.S.S. method)

Gas cylinders

  • Are cylinders stored properly?

  • Photo

Sprinklers

Equipment Guarding

Are these guarded?

  • Pulleys?

  • Belt heads?

  • Tail shafts?

  • Chains?

  • Sprockets?

  • Falling rock areas?

  • Danger signs present?

  • Nip points?

  • Crush points?

Confined Space

  • Permit to enter confined space?

  • Entrance/Exit clearly marked?

  • Spotter present?

4 Gas Meter

  • 4 gas meter sample taken before entering confined space?

  • Meter "bump" tested?

  • Employee equipped with 4 gas meter?

Rescue Plan

  • Rescue equipment within proximity of entrance/exit?

  • Do employees know rescue plan?

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.