Title Page

  • Project Name/ Number

  • Project Location
  • Project Manager

  • Project Engineer

  • Supervisor/ Foreman

  • Number of Employees

  • Conducted on

  • Prepared by

General Assessment

Hazard Communication

  • SDS and Chemical lists maintained on site

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Has SDS and Chemical list been updated for new products?

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Proper identification labels on cans/ portable containers

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

Housekeeping

  • Proper rebar caps used to eliminate impalement

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Work areas clean of excess construction debris

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Nails pulled from wood before handling

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Proper storage of materials, supplies, and equipment (Gangbox, Sea Box, etc.)

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Proper walkway maintained (ice, oil, chords, airlines, etc.)

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

Job Site Requirements

  • Emergency Action Plan posted

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • First aid / Eye wash / Bloodborne Kits available & maintained

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • OSHA (5 in 1) minimum wage, discrimination, state posters

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

Public/ Other Worker Protection

  • Pedestrian signs; barriers; fences; gates; flagging

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Pedestrian walkways protected from trip and slip hazards

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Dust curtains are taped W/ doors and access areas

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Life rings, 90 feet of rope and air horn near water hazards

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Open holes covered and secured and/or barricaded with fencing or guardrails

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Overhead protection (falling; flying debris; tool and equipment)

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Property's glass; tile; flooring and vehicles protected

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Traffic controls maintained (signs, direction, barricades)

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

Safety Culture

  • Project planning documents onsite and have been reviewed with employees

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Task Planning completed for unidentified or new tasks

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Project is utilizing safety culture programs (i.e. Safety 24/7, Frontline Safety, Mentoring Programs)

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

Sanitation

  • Drinking water is available

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • If not using bottled water, are drinking coolers properly maintained, sanitized, and labeled

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Proper means of disposal (dumpsters, trash cans)

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Proper number of toilets and wash-up facility provided

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

Commercial (Non-Elevated)

Aerial Lifts: (Articulated, Scissor)

  • Area around swing radius is properly barricaded

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Workplace hazards identified before use

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Employees maintaining fall protection attachment(s)

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Railings not used for work access

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Stable, level drive area

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Equipment not used as a crane to lift materials

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

Compressed Air and Gas Cylinder Safety

  • Air compressors properly maintained and used

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • All connections are double pinned with whip check installed

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Compressed air receiver tanks equipped with blow off valve

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Threaded connection for airlines (2" or greater)

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • OSHA valves installed on 1/2" or greater inside diameter hose (3/4" outside diameter or greater)

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Compressed gas cylinders stored and secured vertically

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Cylinders have caps installed when not in use

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Flash back arresters installed at cylinder regulator

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Oxygen and fuel gases stored 20' apart or separated by fire proof wall

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

Electrical Safety

  • Adequate lighting for work areas (guarded lenses)

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Assured grounding inspection or GFCI is in use

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Electric panel boxes have proper covers

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Extension cords are 12 gauge/ 3 wire minimum

  • Comments:

  • Due Date:

  • Action Completed:

  • Person Assigned:

  • Comments:

Fall Protection

  • Anchor point of 5000 lbs. per employee or engineered anchorage

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Floor and walkway openings protected

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Employees are maintaining 100% fall protection program

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Vertical and/or horizontal life lines properly installed and inspected

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Handrails are properly constructed- top middle and toe board

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

Fire Safety

  • Equipment turned off while fueling

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Exit, stairs, and walkways are clear (36" minimum walkway)

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Fire extinguishers are of adequate size and placement (10 lb. min.)

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Flammable storage area is 20' from buildings

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Flammables and combustibles stored separately

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Fuels cans no larger than 5 gallon with flash arrestor/ spring locks

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Fuel storage area: signs/ containment/ >20 lbs. extinguisher

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • No smoking signs posted (smoking areas clearly marked)

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Oily rags stored in proper container W/ self closing lid

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Welding/ burning: No combustibles/ fire extinguisher present

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Hot work permit in use (when required)

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

Hand Tools and Power Equipment

  • Power equipment clean and free of damage

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Grinders used with guards and side handles at all times

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Hand tools maintained and free of damage

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Hand tools secured from falling (working at heights)

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Power tools are double insulated with proper grounding connection

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Running equipment not left unattended

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Sand pots: properly used, clean, and free of damage

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Pressure washers: properly used, clean, and free of damage

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Saws: properly used, clean and free of damage

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

Lock-Out/ Tag-Out Program

  • Energy isolation devices identified and secured

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Group lock-out box in use with supervisor's lock in place

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Individual employee locks are labeled and in use

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Lock-out point has a "Do Not Operate" tag attached

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Written program in place (company or client provided)

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Tags are completely filled out

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

Motorized Equip. (Forklift; Con. Buggie; Skid Steer)

  • Equipment inspection completed before use (daily)

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Lift is used within rated capacity

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Attachments inspected and manufactured for intended use

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

Mixing/ Grouting/ Gunite Equipment

  • Dust containments are established in public areas

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Employees are wearing correct PPE for identified tasks

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Equipment is shut down for cleaning (LO/TO where needed)

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Machines are maintained and appear to be fully operational

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Material placement does not create tripping hazards

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Team lifting practices for bags (50 lb. or greater)

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

Personal Protective Equipment

  • Chemical Protective Clothing (Tyvek, Rain Suits, Etc.)

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Hard hats are being worn properly and are in good condition

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Eye protection (Z-87.1+ and rated for Task)

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Flotation devices (PFD- Personal Flotation Device)

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Appropriate gloves for the identified task

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Hearing Protection (Noise levels greater than 85 dB)

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Work Boots: Leather / Safety Toe (Steel or Composite)

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Reflective Clothing/ Vests- As determined by project

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

Respiratory Protection

  • All airborne (respiratory hazards) have been identified

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Employees are clean shaven when using respiratory protection

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Fitted respirator users trained, provided physicals, and fit tested

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Proper respiratory protection has been selected for hazards

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Respiratory cleaning/ disinfection supplies provided

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Respirators are stored in protective bags when not in use

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Respirators are being worn properly

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

Structure Safety and Protection

  • Has shoring been properly implemented and maintained

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Is loose and delaminated concrete removed prior to working

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Is shoring left in place until completion of proper cure time

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Is shoring placed around columns when concrete removed

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Is structure capable of supporting construction equipment and debris

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Is there point loading of materials or debris on elevated decks

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

Scaffold And Ladder Access

  • Ladder tip extends 36" beyond landing area

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Ladders are inspected daily and in good working condition

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Ladders are installed with 4:1 standard ratio

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Ladders are secured before employee work begins

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Ladders are non-conductive and have non-skid feet

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Scaffold has adequate cross bracing with positive locking devices

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Scaffold modifications made by competent person only

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Scaffolding system is properly tagged and inspected

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Work decks are secured to scaffolding and free of debris

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Work decks are complete without spacing/ openings

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

Storage (equipment/ Supplies)

  • Protected from vehicle and pedestrian traffic

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Secure area (fencing or other enclosure) off hours

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Flammable cabinets are in use (20 gal or greater)

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Equipment is barricaded while being operated

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

Traffic Control (Active Garages)

  • Barricades for equipment, men working, etc.

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Traffic lanes well marked

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Blind spots are identified

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Pedestrian walkways are clearly marked/ barricaded

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Adequate lighting provide for pedestrian walk ways

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Adequate lighting for work crews

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Work crews is using type- II reflective clothing

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

Trenching/ Excavation Safety

  • Competent person evaluating: shoring, benching, sloping

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Excavation access are properly guarded at ground level

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Excavation is being monitored for gases (greater than 4' deep)

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Ladder access provided (min. 25' travel distance) for entry and exits

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Shoring devices are engineered and in good working condition

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

General Notes or 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.