Title Page
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Conducted on
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Prepared by
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Heading
Safety Inspection
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Daily 5-Point Card Completed
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RESPONSE
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ASSIGNED TO
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Who corrected it?
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Work Area Scaled-2 scaling Bars
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Response
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ASSIGNED TO
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Who corrected it?
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Work Area Clean and Organized
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RESPONSE
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ASSIGNED TO
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Who corrected it?
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PPE Worn
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RESPONSE
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ASSIGNED TO
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Who corrected it?
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1 Meter clearance around PowerPack
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RESPONSE
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ASSIGNED TO
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Who corrected it?
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Roadways clean
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RESPONSE
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ASSIGNED TO
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Who corrected it?
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Wire in Good Shape, No Eye Catchers
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RESPONSE
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ASSIGNED TO
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Who corrected it?
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No Protruding Rock Bolts
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RESPONSE
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ASSIGNED TO
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Who corrected it?
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Rods secured in rack
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RESPONSE
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ASSIGNED TO
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Who corrected it?
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Face Plate Properly Anchored
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RESPONSE
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ASSIGNED TO
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Who corrected it?
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Station well lit
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RESPONSE
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ASSIGNED TO
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Who corrected it?
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Barricades and Signs in Place
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RESPONSE
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ASSIGNED TO
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Who corrected it?
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Refuge location known
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RESPONSE
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ASSIGNED TO
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Who corrected it?
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Guards in Place
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RESPONSE
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ASSIGNED TO
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Who corrected it?
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Drinking Water Available?
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RESPONSE
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ASSIGNED TO
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Who corrected it?
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Walkways clear 36" or greater
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RESPONSE
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ASSIGNED TO
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Who corrected it?
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Mine Phone Operational in Work Area
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RESPONSE
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ASSIGNED TO
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Who corrected it?
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Utilites Hung Properly
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RESPONSE
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ASSIGNED TO
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Who corrected it?
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Whip Checks in Place
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RESPONSE
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ASSIGNED TO
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Who corrected it?
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Ventilation Sweeping Face
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RESPONSE
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ASSIGNED TO
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Who corrected it?
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No Holes in Ventilation
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RESPONSE
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ASSIGNED TO
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Who corrected it?
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Flammables and oil cans properly labeled?
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RESPONSE
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ASSIGNED TO
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Who corrected it?
Pre-Op For Equipment
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Mobile Equipment in Good Shape
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RESPONSE
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ASSIGNED TO
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Who corrected it?
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Platform stable and well constructed
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RESPONSE
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ASSIGNED TO
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Who corrected it?
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Wheel Chocks Available on Equipment
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RESPONSE
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ASSIGNED TO
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Who corrected it?
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No Visible Leaks on Equipment
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RESPONSE
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ASSIGNED TO
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Who corrected it?
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Hand Tools in Good Shape
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RESPONSE
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ASSIGNED TO
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Who corrected it?
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Fire Extinguishers in Good Shape
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RESPONSE
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ASSIGNED TO
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Who corrected it?
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First Aid Kits Current
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RESPONSE
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ASSIGNED TO
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Who corrected it?
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Emergency shutdowns operational
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RESPONSE
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ASSIGNED TO
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Who corrected it?
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Cable & Attachments in good shape
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RESPONSE
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ASSIGNED TO
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Who corrected it?
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Vehicles Chocked and Park Brake Set
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RESPONSE
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ASSIGNED TO
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Who corrected it?
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Employee current on Task Training
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RESPONSE
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ASSIGNED TO
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Who corrected it?
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Hydraulic Hoses in good condition
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RESPONSE
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ASSIGNED TO
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Who corrected it?
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Hose Wrap in good shape
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RESPONSE
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ASSIGNED TO
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Who corrected it?
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Electrical cables properly hung clear walkway to First aid supplies
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RESPONSE
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ASSIGNED TO
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Who corrected it?
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Trash Cans used with Lids
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RESPONSE
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ASSIGNED TO
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Who corrected it?
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Lock-Out Tag-Out available
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RESPONSE
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ASSIGNED TO
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Who corrected it?
ACKNOWLEDGEMENT
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By signing below, you are acknowledging that the following PGI has been reviewed by all parties involved in this audit. All answered marked; NO, AT RISK, or NEEDS WORK have been addressed and will be fixed or corrected before the end of the shift on the date this audit was conducted on. All CORRECTED answers must be signed by the person correcting the issue at the time of the inspection.
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DRILLER NAME
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HELPER NAME
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HELPER NAME
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SUPERVISOR NAME
AUDITOR
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AUDITOR NAME
SITE SUPERVISOR REVIEWED
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SUPERVISOR NAME
