Information
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Company / Project Name:
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Conducted on
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Location
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Prepared by
General Safety
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General housekeeping efforts kept up
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General precautions taken to protect property and patrons from damages/injury (ie flying debris secured)
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Intakes covered or turned off when chemicals used
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Other
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Fall Protection
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Check only if Fall Hazards of 6' or greater are present at the project (examples of projects with no fall hazards include work on the ground or parapet walls 39" or greater fully surrounding the roof with no skylight hazards )
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Warning Line Systems (if not checked than N/A)
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Warning lines completely enclose the roof area, are 6' from edge (10' if mechanical equipment in use) and properly maintained
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Employees adhering with requirement and remaining inside warning lines unless using a different fall protection system
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Points of access connected to work area by access path formed by two lines. When not in use, a warning line is run across the path to fully enclose the work area
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Guardrails System (if not checked than N/A)
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Top rail 39-45 inches above the walking working surface. Cable deflects 3" or less and does not sag below 39" with 200lbs of force applied.
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Guardrail system properly installed capable of withstanding 200lbs of force
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Standard toe boards installed if exposure below exists
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Personal Fall Arrest Systems (if not checked than N/A)
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Equipment inspected prior to use
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Sufficient 5K pound anchor points in use. If temporary anchors are used, they are installed in accordance with manufacturers requirement.
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Harness & lanyards worn and adjusted properly. Lifelines installed properly, slack removed, pendulum effect and free fall distance considered and controlled
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Anchorage connectors such as cross arm straps utilized to wrap units / structures. No wrapping of lifelines / lanyards and hooking them back to themselves
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Skylight and hole protection (if not checked than N/A)
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Skylight / holes protected by guardrail, cover, net, warning lines 15' away or personal fall arrest system is used
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Hole covers capable of withstanding twice the intended load. "Hole" or "Cover" painted atop the cover
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Hoist area fall protection (if not checked than N/A)
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Guardrails or PFAS utilized in hoisting areas (areas where material / debris / equipment is being brought up to or removed from roof)
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Employees using PFAS in hoist areas set them up for fall restraint
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Safety Monitoring System (if not checked than N/A)
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A safety monitor has been approved for this project by upper management? IF NOT, DO NOT PERMIT MONITORING USE.
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Safety monitor in audible & visual distance, on same working level and performing monitoring duties only
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Safety monitor educated to recognize fall hazards and aware of items that he/she should be looking for
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Monitor used in conjunction with warning line, except for on roofs that are <50' in length or width
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Employees ensuring a safety monitor is present prior to going outside warning lines or working on an unprotected roof
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Additional monitors used as needed if employees being monitored are spread out further than one can safely monitor.
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Other
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Personal Protective Equipment
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Hard hat / Eye protection worn when hazard exits and per policy
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Proper gloves worn when handling tear off debris, when handling sharp metal, and when handling chemicals requiring glove usage
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Proper work attire worn (boots, pants, sleeved shirts, long sleeve shirts if handling hot asphalt)
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Other
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Access / Egress
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Portable Ladders (if not checked than N/A)
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In good safe working condition. Proper ladder for the job.
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Ladder extends 3' over landing, set up at proper angle (1ft off the base for every 4' vertical) and tied off securely?
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3 points of contact maintained while climbing
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Ladders removed when leaving and unsecured site
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Other
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Fixed Ladders (if not checked than N/A)
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Ladder in good repair, no visible damage
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Fall protection or cage available if 24' in height or greater
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Minimum clearance between ladder and obstruction behind is 7"
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Inside of cage or well is free of obstructions
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Other
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Stepladders (if not checked than N/A)
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Stepladders in good repair. No visible damage to rails, rungs, or spreader
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Ladder used in an open a-frame position
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Proper ladder size used. Climbing on top of stepladder, or on first rung from the top, is prohibited
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Other
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Stairs (if not checked than N/A)
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Metal pan stairs are filled with with suitable material or barricaded to prevent access
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Stairways with four or more risers have stair rails provided on each unprotected edge and/or hand rails to hold during use
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Other
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Other
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Electrical Safety
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GFCI utilized at all times
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Cords and tools in good condition. Damaged cords / tools tagged out of service or rendered inoperable
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All ladders and equipment at least 10' from electrical lines
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All cords protected from damage, not being run over by vehicles or slammed in door or window jams
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Other
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Fire Prevention
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Extinguishers in place, charged and in work area. Clear of obstruction. No more than 100' from employees, no more than 50' from flammables
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No smoking near flammables
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Proper metal flammable safety cans in use
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Other
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Material Handling
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Material handling equipment in good condition
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Debris removed of promptly and safely. When over 20', Material not thrown off building unless enclosed Chute provided.
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Crane Safety (if not checked than N/A)
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Operators licensed / certified
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Rigging in good condition. Capacities legible. Inspected prior to use with no visible damage.
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Qualified rigger / signal person used
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Forklift Safety (if not checked than N/A)
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Operator certified. License available and current (not more than 3 years old)
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Seatbelt worn at all times
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Safe speeds maintained
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Other
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Scaffolding
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Supported Scaffolding (if not checked than N/A)
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Competent person onsite - daily inspections conducted
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All components in good condition, properly assembled
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Safe access onto scaffold available
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Guardrails and toeboards on all open sides of work area
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Work platform fully decked with proper overhang / cleating of planks
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All employees using have user training
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Scaffold kept a safe distance (10' minimum) from overhead powerlines unless lines have been de-energized or other acceptable safeguards implemented
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Falling object protection adequate if exposure below exists. Toe boards in place, or netting used if material stacked higher than toe boards
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Aerial Lifts (if not checked than N/A)
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All employees using have received user training
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Proper fall protection in place when working from boom lift. Retractable lanyard or other restraining device used. Harness worn properly
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Equipment kept a safe distance from overhead powerlines (minimum of 10' unless power lines are de-energized or other acceptable safeguard is implemented)
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Other
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Sign Off
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Foreman Signature
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Inspector Signature
