Information
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Audit Title
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Document No.
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
JSA
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Is JSA Complete?
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Has Onsite Personnel Signed The JSA?
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Other
Required PPE
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Hard Hat
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Safety Glasses
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Face Shield / Goggles
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Hearing Protection
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Gloves
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ANSI 107 Class II or III Safety Vest
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Foot Protection / Safety Toe
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FRC Clothing
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Dust Mask
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Other:
Excavation
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Excavation Type:
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Is the excavation less than 20' deep?
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Documented Inspection by Competent Person
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Benched or Sloped Properly = Class A -3/4:1 Class B -1:1 Class C-1 1/2:1
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Access / Egress Within 25' Of Entrants?
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Trench Box/Shoring Proper
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Trench Box Certifications
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Spoil Pile Minimum 2-Feet From Excavation
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Signs, Signals & Barricades
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One Call Valid
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Utilities Identified
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Other:
Material Handling
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Body Mechanics
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Position of People
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Manual Lifting Devices (Come-a-Longs, Chain falls, etc )
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Safety Latch
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Slings
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Hooks & Shackles
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Wire Rope
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Lifting Chains
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Load Secure, Rigged Properly
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Tag Lines Used
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Other:
Vehicle/Equipment/Crane
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Authorized/Qualified Operator
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Designated Signal Person
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Seatbelt Used
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Daily/Weekly/Annual Inspection
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Other:
Housekeeping
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Dunnage
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Trash
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Trash Receptacles
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Crew Trucks/Trailers
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Other
Material Storage
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Material Stored Properly
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Flammable/Combustible Storage
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Pipe Chocked
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Other:
Electrical
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GFCI/Assured Grounding Program
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Cords/Tools Inspected
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Cords Routed Properly
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Other:
Hot Work
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Permit
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Permit Conditions Followed
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Fire Watch
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Other:
Welding
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Grinder Condition
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Guards/Handles
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Leads/Hoses/Gauges
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Bottle Storage
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Other:
Fire Protection & Prevention
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Fire Suppression Equipment
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Fire Extinguisher Inspection
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Properly Rated/Size (BC versus ABC)
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Combustible/Flammable Material Away from Hot Work
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Other:
Traffic Control
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Designated Flagger With Cones
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Signs Posted per MUTCD
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Escort Required/Used
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Other
Signs/Barricades
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Condition
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Proper Type
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Appropriate Location
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Marking Hazards
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Other:
Overhead Power Lines
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Power Lines Marked with Goal Post and/or Signs
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Designated Spotter
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Other
X-Ray
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Signs, Signals & Barricades
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Other
Lock-Out/Tag-Out
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Potential Energy Sources Identified
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Isolated
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Verified
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Affected Personnel Informed
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Other
Miscellaneous
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Restrooms & Potable Water Available
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First Aid Kit
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Confined Space
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Fall Protection