Title Page

  • Conducted on

  • Prepared by

  • Location
    Hazard Identified
  • Document the findings with a photo:

  • List Hazard:

  • MMA's Recommendation:

  • Ensure Written program is updated annually with goals and objectives.

  • Ensure Guards are properly adjusted to 1/8" on tool rest & 1/4 inch on top guard. See photo for additional information:

    benchgrinder.jpg
  • Ensure that all cranes and hoists are inspected regularly, and that the inspection is documented.

  • Ensure that all excavations greater than 5 feet are protected with a protection system, trench box, sloping, shielding.

  • Ladders should be used for depths greater than 4 feet and should be spaced 25 feet apart.

  • Spoil Piles should be set back at least 2 feet from the edge of the excavation.

  • No bare wires should be seen through the insulation of wires.

  • Ensure all wiring components are guarded properly.

  • Electrical components should be grounded or double insulated.

  • Construction equipment should be used with a Ground Fault Circuit Interrupter (GFCI) at all times.

  • Strain Relief should be intact.

  • Ensure that all employees are Personal Fall Arrest System while in the work basket.

  • Ensure all hazardous substance containers are labeled properly with a GHS complaint label.

  • Ensure all employees are trained annually.

  • Ensure that all Fall Protection is inspected daily.

  • Guard all Open Side, Hole, Wall Opening

  • Ensure that fall protection is used when within 15’ of fall hazard on flat roof

  • Ensure that all fire extinguishers are not blocked at all times.

  • Ensure that all fire extinguishers are inspected at least monthly (in-house) & Annual (third party).

  • Ensure that all fire extinguishers gauges are in the green.

  • Ensure that all ladders are stored properly to prevent falling.

  • Ensure that all ladders are inspected before use, and any damaged ladders are removed from service or red-tagged.

  • Ensure the proper type and use of ladders is being followed. Training of employees about proper ladder use.

  • Ensure that LOTO Procedures are written for all dual energy machines.

  • Ensure that LOTO training is conducted for both authorized and affected employees.

  • Ensure that all LOTO Procedures are audited on an annual basis.

  • Ensure that all Point of Operation is guarded to protect employees from coming in contact with the Point of Operation.

  • Ensure that PPE is proper for the hazards trying to protect against.

  • Ensure that PPE is in good working order.

  • Ensure that PPE is ANSI or ASME rated.

  • Ensure that Forklifts are inspected daily.

  • Ensure that Forklift Damage is reported and repaired.

  • Ensure that Forklifts are parked and turned off when operator is greater than 25 feet away or out of site of the forklift.

  • Ensure that Carbon Monoxide testing is completed & documented quarterly for environmental exposure, not just tail pipe testing.

  • Ensure that all Respirators are cleaned, stored, and used in appropriate manner.

  • Ensure that all employees have signed Appendix D when using voluntarily.

  • Ensure all required users are trained, medically evaluated, and fit tested annually as required by the Respiratory Protection Standard.

  • Ensure that Scaffolds are Tied/Secured >4:1 Base height

  • Ensure that guardrail system is not missing or incomplete.

  • Ensure that all pins are in place.

  • Ensure that proper Foundation/Base is being used.

  • Enter Recommendation here:

  • Enter Recommendation Here:

  • Potential OSHA Penalties

Corrective Action:

  • Corrective Action Taken:

  • Corrective Action completed:

  • Verification of corrective action:

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.