Information
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Project/Job #
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Project/Job
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Conducted on
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Prepared by
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Location
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Personnel
BEHAVIOR
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TSSP reviewed and signed?
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TSSP for each task?
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Mentors Assigned
WORK AREAS
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General Housekeeping
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Dust Control (i.e. carpenter's shed)
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Walking - Working Surfaces
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Impalement Hazards
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Sanitary Facilities
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Trash Receptacles
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Material Storage/Lay Down
JOB SITE POSTERS
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All OSHA Required Posters
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Emergency Evacuations
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Emergency Contacts List
HEALTH/FIRST AID
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CPR/First AidTraining
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First Aid Kit (No Expired Items)
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Eye Wash Facilities
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Access to Eye Wash
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AED inspected
PERSONAL PROTECTIVE EQUIPMENT
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Safety Glasses with Side Shields
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Face Shield / Goggles (If Required)
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Hearing Protection (If required)
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Clothing (Welding Leathers, Hi-Viz, etc. if required)
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Gloves
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Foot Protection
FALL PROTECTION
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Worn Properly
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Suitable Anchorage Points
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Inspected/Color Coded
LADDERS
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Base/Footing/Set Up
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Inspections/Color Coded
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Proper Type for Task
HAND AND POWER TOOLS
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In Good Condition
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Inspected/Color Coded
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Whip-Checks
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Machine Guarding
ELECTRICAL
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G.F.C.I.'s
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Extension Cords
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Power Tools
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Lock Out/Tag Out
FIRE SAFETY
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Fire Extinguisher/Inspected
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Combustibles removed/isolated
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Hot Work Barricade (if required)
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Gas Can(s)
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Fire Extinguisher w/in 50'of portable fuel storage
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Portable fuel storage secured
RIGGING AND HOISTING
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Capacity Tags
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Hooks and Latches
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Tag Lines
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Qualified Rigger
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Stored Properly
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Damage
EQUIPMENT
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Equipment Inspections completed
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Operator Qualified and Certified
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Spotter (if necessary)
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Proper setup and use
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LOTO/Equipment Maintenance
HAZCOM
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SDS for all Chemicals on Site
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Proper Storage of Chemicals
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Proper PPE for Handling Chemicals
OTHER
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A.
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B.
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C.
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D.
Comments/Recommendations
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Enter any corrective actions that will be undertaken
Sign Off
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Safety Representative
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Production Leader
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OSC Rep / Others
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OSC Rep / Others