Monthly Site Inspection & Equipment Checklist

• Machine #

• Location
  Address

• Date

  Date

• Inspected by:

• Nearest First Aid Attendant:

• ETV Location
  Address

• Number of Fire Tools, Extinguishers:

• Number of Spill Kits:

• First Aid Kit Level:

  Level 1

  Level 2

  Level 3

  N/A

PPE / Tools / Machine

• Hi-Vis / Hard Hat / Gloves

  Good

  Repair

  Replace

• Eye / Ear Protection

  Good

  Repair

  Replace

• Footwear

  Good

  Repair

  Replace

• Seatbelt / Seat condition

  Good

  Repair

  Replace

• Machine location communicated to other crews

  Good

  Repair

  Replace

• No loose gear in cab

  Good

  Repair

  Replace

• Windows / Mirrors / Wipers

  Good

  Repair

  Replace

• Stairs / Ladders / Railings

  Good

  Repair

  Replace

• Exhaust system

  Good

  Repair

  Replace

• Trip / Slip 3 point contact used

  Good

  Repair

  Replace

• Siltation control

  Good

  Repair

  Replace

• Work plan discussed

  Good

  Repair

  Replace

• Ditches / Culverts maintained

  Good

  Repair

  Replace

• Tire chain / Tow strap condition

  Good

  Repair

  Replace

• Leaks managed / Litter removed

  Good

  Repair

  Replace

• In Case of Accident Sheet in Grader

  Good

  Repair

  Replace

• Operator Signature:

  Sign