Preliminary Safety Review

• Document No.

• Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Project Name:

• Preposed start date

• Description of building to be building (i.e. four story with retail)

Dimensions

• Height

Materials

• Foundation:

• Walls:

• Floors:

• Demolition Required

• Potential external hazards ( occupied buildings, close proximity to an airport etc.):

• Hazards requiring additional Safety Analysis:

• Item #s requiring Professional Engineer input:

Safety Exposures

• Natural gas lines

  Yes

  No

• Electrical lines

  Yes

  No

• Water lines

  Yes

  No

• Fiber optic cables

  Yes

  No

• Other utilities

  Yes

  No

• Fire hazards

  Yes

  No

• Adjacent walkways

  Yes

  No

• Adjacent roadways

  Yes

  No

• Adjacent buildings

  Yes

  No

• Railroad tracks and crossings

  Yes

  No

• Heavy equipment hazards

  Yes

  No

• Confined space hazards

  Yes

  No

• Shoring required

  Yes

  No

• Basement

  Yes

  No

• Open pits or trenches

  Yes

  No

• Manholes to preserve

  Yes

  No

• Fall hazards

  Yes

  No

• Lead exposure

  Yes

  No

• Process hazards

  Yes

  No

• Utilities to disable

  Yes

  No

• Pre-existing structural damage

  Yes

  No

• Environmental issues

  Yes

  No

• Other safety issues

• I have reviewed this preliminary survey with the safety department and have had the opportunity to have it amended to include any additional concerns that I have identified.

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