Title Page
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Document Nr.
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Customer / Site
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Location
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Executed on
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Performed by
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Involved personnel
BODY POSITION
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BODY MECHANICS: Close to load, proper lifting, squared up to task (no twisting), using mechanical lift if possible, assisted if too heavy.
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ASCEND/DESCENS: 3 points of contact.
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PINCH POINTS: Body parts kept clear from crush point, pinch points, and cuts.
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EYES ON TASK: Face/head in direction of travel. Watch hands engaged in tasks.
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LINE OF FIRE: Not working/standing in path of equipment/materials that may shift, relieve pressure, move, or fall.
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OVEREXTENDED/CRAMPED: Overextending to pass materials/working in cluttered cramped areas that limit movement.
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STAY TO RIGHT: When passing material take one step to the right of person below
TOOLS & EQUIPMENT
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TOOL SELECTION/USE: Right tool used in the manner intended.
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TOOL CONDITION: Tools in working order.
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TOOLS INSPECTION: Color code as per quarter.
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EQUIPMENT SELECTION/USE: guards in place, de-energized for maintenance.
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EQUIPMENT CONDITION: Electrical cords fray free.
PERSONAL PROTECTIVE EQUIPMENT
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RESPIRATORY PROTECTION: Selection, condition, and use of respirator
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FIT TEST: Respirator fit test completed if required.
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EYE PROTECTION: Proper eye/face protection present and in use.
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HAND PROTECTION: Proper hand/arm protection present and in use.
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HEARING PROTECTION: Hearing protection in use - Double hearing protection in use if required.
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PROTECTIVE CLOTHING: Proper protective clothing in use (FRC, Latex suit, life vests, etc.).
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FOOT PROTECTION: Proper footwear worn.
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HEAD PROTECTION: Proper use of hard hat (bib forward).
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HARNESS: Proper wear/use of harness.
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LANYARD SELECTION: Proper lanyard selection for the job (retractable, 6ft lifeline, etc.).
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LANYARD USE: Proper wear/use of lanyard.
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ANCHOR POINT: Tied off to suitable anchor.
NRTR / JSP / JOB PLAN
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NRTR / JSP COMPLETED: All components of the NRTR / JSP completed prior to starting work.
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WORKPLACE DESIGN: Is job site designed to prevent possible contact with hazards.
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MAJOR STEPS OF TASK: Key steps of the task noted on NRTR / JSP.
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HAZARD IDENTIFIED: Are hazards identified and noted on NRTR.
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AREA-SPECIFIC HAZARDS: Are area specific hazards identified.
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SAFE PLAN OF ACTION: Safe work plan developed to avoid and minimize exposure to risk.
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MITIGATION: Mitigation steps in place for identified hazards.
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SIGNED BY SUPERVISOR: Supervisor signed NRTR / JSP within first hour of work starting.
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SIGNED BY CREW: All crew members signed NRTR / JSP prior to starting work
ENVIRONMENT
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WALKING SURFACES: Walking surfaces free of hazards.
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WORKING SURFACES: Working surface free of hazards.
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ADEQUATE ILLUMINATION: Adequate lighting for the work being performed.
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HYGIENE: Industrial hygiene practices utilized where needed (e.g. LEL, Oxygen-, CO levels).
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VENTILATION: Adequate means of ventilation of confined areas.
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HOUSEKEEPING: Proper housekeeping.
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STORAGE: Storage area neat and orderly.
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BARRICADES/WARNINGS: Proper barricades and warning signs present.
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BARRICADE TAGS: Tags proper filled out
PROCEDURE RELATED
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PRE-JOB PLANNING: Supervision conducted team planning meeting to communicate work task.
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COMMUNICATION OF HAZARDS: All known hazards communicated prior to starting.
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CONFINED SPACE: Confined space procedure followed.
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LOTO: Lock-Out / Tag-Out procedure followed.
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SENSITIVE EQUIPMENT: All sensitive equipment tagged and steps taken to mitigate hazard/damage.
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PERMITS: Permits present, filled out, signed, being followed.
MOBILE EQUIPMENT OPERATION
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FORKLIFT DAILY INSPECTION: Inspection completed and documented.
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FORKLIFT CERTIFICATION: Driver has current forklift certification.
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VEHICLE DAILY INSPECTION: Inspection completed and documented.
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Approved and competent driver.
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SPOTTER / WATCH MAN: Spotter or Guard required and in place.
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SEAT BELTS: Driver (and passengers) wearing seatbelt(s).
ADDITIONAL COMMENTS
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Comments and/or remarks.
