Information

  • Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

JSA

  • Is JSA Complete?

  • Has Onsite Personnel Signed The JSA?

  • Other

Required PPE

  • Hard Hat

  • Safety Glasses

  • Face Shield / Goggles

  • Hearing Protection

  • Gloves

  • ANSI 107 Class II or III Safety Vest

  • Foot Protection / Safety Toe

  • FRC Clothing

  • Dust Mask

  • Other:

Excavation

  • Excavation Type:

  • Is the excavation less than 20' deep?

  • Documented Inspection by Competent Person

  • Benched or Sloped Properly = Class A -3/4:1 Class B -1:1 Class C-1 1/2:1

  • Access / Egress Within 25' Of Entrants?

  • Trench Box/Shoring Proper

  • Trench Box Certifications

  • Spoil Pile Minimum 2-Feet From Excavation

  • Signs, Signals & Barricades

  • One Call Valid

  • Utilities Identified

  • Other:

Material Handling

  • Body Mechanics

  • Position of People

  • Manual Lifting Devices (Come-a-Longs, Chain falls, etc…)

  • Safety Latch

  • Slings

  • Hooks & Shackles

  • Wire Rope

  • Lifting Chains

  • Load Secure, Rigged Properly

  • Tag Lines Used

  • Other:

Vehicle/Equipment/Crane

  • Authorized/Qualified Operator

  • Designated Signal Person

  • Seatbelt Used

  • Daily/Weekly/Annual Inspection

  • Other:

Housekeeping

  • Dunnage

  • Trash

  • Trash Receptacles

  • Crew Trucks/Trailers

  • Other

Material Storage

  • Material Stored Properly

  • Flammable/Combustible Storage

  • Pipe Chocked

  • Other:

Electrical

  • GFCI/Assured Grounding Program

  • Cords/Tools – Inspected

  • Cords Routed Properly

  • Other:

Hot Work

  • Permit

  • Permit Conditions Followed

  • Fire Watch

  • Other:

Welding

  • Grinder Condition

  • Guards/Handles

  • Leads/Hoses/Gauges

  • Bottle Storage

  • Other:

Fire Protection & Prevention

  • Fire Suppression Equipment

  • Fire Extinguisher Inspection

  • Properly Rated/Size (BC versus ABC)

  • Combustible/Flammable Material Away from Hot Work

  • Other:

Traffic Control

  • Designated Flagger With Cones

  • Signs Posted per MUTCD

  • Escort Required/Used

  • Other

Signs/Barricades

  • Condition

  • Proper Type

  • Appropriate Location

  • Marking Hazards

  • Other:

Overhead Power Lines

  • Power Lines Marked with Goal Post and/or Signs

  • Designated Spotter

  • Other

X-Ray

  • Signs, Signals & Barricades

  • Other

Lock-Out/Tag-Out

  • Potential Energy Sources Identified

  • Isolated

  • Verified

  • Affected Personnel Informed

  • Other

Miscellaneous

  • Restrooms & Potable Water Available

  • First Aid Kit

  • Confined Space

  • Fall Protection

Closing Comments

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.