PULLMAN- Revised Industrial (Nuclear, Chemical, Power, Pipe) SMLT

• Project Name/ Number

• Project Location
  Address

• Project Manager

• Project Engineer

• Supervisor/ Foreman

• Number of Employees

• Conducted on

  Date

• Prepared by

Hazard Communication

• SDS andChemical lists maintained on site

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

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

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Proper identification labels on cans/ portable containers

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

Housekeeping

• Proper rebar caps used to eliminate impalement

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Work areas clean of excess construction debris

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Nails pulled from wood before handling

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

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

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

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

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

Job Site Requirements

• Emergency Action Plan posted

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

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

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

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

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

Public/ Other Worker Protection

• Pedestrian signs; barriers; fences; gates; flagging

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Pedestrian walkways protected from trip and slip hazards

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Dust curtains are taped W/ doors and access areas

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

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

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Open holes covered or barricaded with fencing or guardrails

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

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

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

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

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Traffic controls maintained (signs, direction, barricades)

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

Safety Culture

• Project planning documents onsite and have been reviewed with employees

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Task planning completed for unidentified or new tasks

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

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

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

Sanitation

• Drinking water is available

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

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

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Proper means of disposal (dumpsters, trash cans)

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Proper number of toilets and wash-up facility provided

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

Aerial Lifts: (Articulated, Scissor)

• Area around swing radius is properly barricaded

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Workplace hazards identified before use

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Employees maintaining fall protection attachment(s)

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Railings not used for work access

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Stable, level drive area

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Equipment not used as a crane to lift materials

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

Compressed Air and Gas Cylinder Safety

• Air compressors properly maintained and used

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• All connections are double pinned with whip check installed

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Compressed air receiver tanks equipped with blow off valve

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Threaded connection for airlines (2" or greater)

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

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

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Compressed gas cylinders stored and secured vertically

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Cylinders have caps installed when not in use

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Flash back arresters installed at cylinder regulator

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

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

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

Confined Space Entry

• Natural/ mechanical ventilation in place

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Atmospheric gas testing completed (pre-entry/ continuous)

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Gas detection equipment is calibrated and used properly

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Required permits current and available at entry point

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Attendant available at entry point (comm. equip. and permits)

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Has emergency services been identified for confined space rescue

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Emergency evacuation procedure in place

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

Cranes/ Lifting Equipment

• Equipment swing radius barricaded

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Lift plans are complete and reviewed with crew before work starts

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Overhead electrical hazards have been identified

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Qualified operators and signal person in use

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Rated load capacities posted on equipment

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

Electrical Safety

• Adequate lighting for work areas (guarded lenses)

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Assured grounding inspection or GFCI is in use

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Electric panel boxes have proper covers

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Extension cords are 12 gauge/ 3 wire minimum

  Pass

  Action Required

  N/A

• Comments:

• Due Date:

• Action Completed:

• Person Assigned:

• Comments:

Elevated Work Access

• Elevated work access properly planned

  Pass

  Action Required

  N/A

• Comments:

• Due Date:

• Action Completed:

• Person Assigned:

• Comments:

• Fall protection measures in place for all work zones

  Pass

  Action Required

  N/A

• Comments:

• Due Date:

• Action Completed:

• Person Assigned:

• Comments:

• Primary and secondary egress routes available for all work zones

  Pass

  Action Required

  N/A

• Comments:

• Due Date:

• Action Completed:

• Person Assigned:

• Comments:

• Emergency rescue plan in place for all work zones

  Pass

  Action Required

  N/A

• Comments:

• Due Date:

• Action Completed:

• Person Assigned:

• Comments:

• Employees are trained on their role in an emergency

  Pass

  Action Required

  N/A

• Comments:

• Due Date:

• Action Completed:

• Person Assigned:

• Comments:

• Operational non-powered descent device on site

  Pass

  Action Required

  N/A

• Comments:

• Due Date:

• Action Completed:

• Person Assigned:

• Comments:

• Adequate level of communication between ground/ upper work elevations

  Pass

  Action Required

  N/A

• Comments:

• Due Date:

• Action Completed:

• Person Assigned:

• Comments:

Fall Protection

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

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Floor and walkway openings protected

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Employees are maintaining 100% fall protection program

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Vertical and horizontal life lines properly used and inspected

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Handrails are properly constructed- top middle and toe board

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

Fire Safety

• Equipment turned off while fueling

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

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

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

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

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Flammable storage area is 20' from buildings

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Flammables and combustibles stored separately

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

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

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

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

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• No smoking signs posted (smoking areas clearly marked)

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

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

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Welding/ burning: No combustibles/ fire extinguisher present

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Hot work permit in use (when required)

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

Hand Tools and Power Equipment

• Power equipment clean and free of damage

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Grinders used with guards and handles at all times

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Hand tools clean and free of damage

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Hand tools secured from falling (working at heights)

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Power tools are double insulated with proper grounding connection

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Running equipment not left unattended

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

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

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

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

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Saws: properly used, clean and free of damage

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

Lock-Out/ Tag-Out Program

• Energy isolation devices identified and secured

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

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

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Individual employee locks are labeled and in use

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

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

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Written program in place (company or client provided)

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Tags are completely filled out

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

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

• Equipment inspection completed before use (daily)

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Lift is used within rated capacity

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Attachments inspected and manufactured for intended use

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

Mixing/ Grouting/ Gunite Equipment

• Dust containments are established in public areas

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Employees are wearing correct PPE for identified tasks

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

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

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Machines are maintained and appear to be fully operational

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Material placement does not create tripping hazards

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

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

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Safety devices are in place and operational

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

Personal Hoist and Man Cages

• Installed correctly (per drawings or manufacturer's recommendation)

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Inspected on a frequent basis

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Defective items are removed from service and/or corrected

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Qualified employee is operating hoist machine

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Drop test procedures in place

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Hoist variance on site

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Hoist machine engine vented to fresh air (CO Monitoring)

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Overhead lifting zone barricaded and properly signed

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Proper signage posted outside lifting zones

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Lifting cables are properly guarded

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Sheaves, pulleys, blocks, etc. properly guarded and installed

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Access landings have proper clearance and fall protection guards

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Man basket usage:

• 1.) Load rating marked on basket

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• 2.) Properly inspected (daily, weekly, monthly, annual)

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• 3.) Operator at controls while load is suspended

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• 4.) Three full wraps on winding drum

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

Personal Protective Equipment

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

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

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

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

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

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Flotation devices (PFD- Personal Flotation Device)

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Appropriate gloves for the identified task

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Hearing Protection (Noise levels greater than 85 dB)

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

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

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

• Reflective Clothing/ Vests- As determined by project

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Comments:

• Person Assigned:

Respiratory Protection

• All airborne (respiratory hazards) have been identified

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Employees are clean shaven when using respiratory protection

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

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

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Proper respiratory protection has been selected for hazards

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Respiratory cleaning/ disinfection supplies provided

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Respirators are stored in protective bags when not in use

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Respirators are being worn properly

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

Scaffold And Ladder Access

• Ladder tip extends 36" beyond landing area

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Ladders are inspected daily and in good working condition

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Ladders are installed with 4:1 standard ratio

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Ladders are secured before employee work begins

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

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

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• 3 points of contact maintained on ladder

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Scaffold has adequate cross bracing with positive locking devices

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Scaffold modifications made by competent person only

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Scaffolding system is properly tagged and inspected

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Work decks are secured to scaffolding and free of debris

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Work decks are complete without spacing/ openings

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

Trenching/ Excavation Safety

• Competent person evaluating: shoring, benching, sloping

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Excavation access are properly guarded at ground level

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

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

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

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

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

• Shoring devices are engineered and in good working condition

  Pass

  Action Required

  N/A

• Comments:

• Date Due:

  Date

• Action Completed:

• Person Assigned:

• Comments:

General Notes or Comments: