Title Page

  • Document No.

  • Audit title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Foreman in charge

Reporting and Investigation Standard

  • Does Employee have current and completed JSA

  • Does the employee have a current and completed HSE Site plan?

  • Dose the employee understand what a near loss / near hit is?

  • Have all injuries been reported?

HSE 002 - Driving Standard

  • Is the Milford vehicle parked in the appropriate area?

  • Has the daily vehicle inspections sheet been properly filled out?

  • Is the overall appearance of the vehicle clean, inside and out?

  • Are all loads secure, both is the cab and bed of the truck?

HSE 003 - PPE

  • Is hard hat in a clean and sanitary condition and with Milford logo?

  • Are safety glasses ANSI / CSA approved and being worn properly ?

  • Are FRC's / Coveralls in good condition without tears or overly dirty with grease or mud?

  • Is employee wearing steel / composite toed boots?

  • Is glove protecting adequate for work assigned?

  • Does employee have a H2S monitor proper placed in the breathing zone and a adequate bump date?

HSE - 009 SSE (short service employee)

  • Are SSE's properly identified by markings on hard hat?

  • Are SSE's with a mentor?

HSE 010 - Emergency Response and Preparedness

  • Dose employee know where the muster point is?

  • Did the employee review the HSE Site Specific Emergency Plan with you upon arrival?

  • Dose the employee know the PASS method when using a fire extinguisher?

  • Dose the employee have a current First Aid / CPR card?

HSE 011 - Hydrogen Sulfide

  • Dose the employee know if there is H2S on location?

  • Has the employee been trained in H2S and have a current card?

HSE 013 - Mechanical Lifting and Heavy Machinery

  • Are lifting chains and straps properly marked with load limits?

  • Are lifting chains and straps inspected?

  • Dose equipment have certified lifting point?

  • Dose the employee have his certification card to operate heavy equipment? if so upload a picture of the card.

  • Is heavy equipment operator, operating with a spotter present and watching the dig?

HSE 017 - Electrical Safety

  • Are extension cords, in good condition, and properly inspected?

  • Are extension cords plugs adequate for Class I Div II environments?

HSE 018 - Scope of Work

  • Can the employee adequately describe their scope of work?

  • Is the employee preforming any job function that is beyond their scope of work in the area?

Other Stand Alone Categories / Questions

  • Are hand-tools handles in good condition?

  • Are tools properly stored in adequate condition?

  • Dose the overall appearance of the location in good order and housekeeping?

  • Do the employee have an adequate supply of water?

STOP WORK Authority

  • can the employee adequately describe STOP WORK Authority?

Manual Lifting

  • Observe the employee. Does the employee use proper ergonomic techniques while lifting?


  • Excavations, adjacent areas, and protective systems inspected by a<br>competent person daily before the start of work.

  • Prior to excavation, was a line finder surveyed over the job?

  • Spoils, materials, and equipment set back at least two feet from the edge of<br>the excavation?

  • Warning vests or other highly visible clothing provided and worn by all<br>employees exposed to public vehicular traffic

  • Is the operator digging within three feet of any known lines or utilitys?

  • Do all employees know not to enter the trench with the depth greater than four foot?

  • Signature of foreman or person in charge.

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