Title Page
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Conducted on
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Prepared by
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Location
Task Details
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Company Conducting Task
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Permits required for task?
- Yes
- No
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Hot Work
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Is permit filled out correctly?
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Is all combustible's out of area?
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Is fire watch in place?
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Does fire watch have fire extinguisher?
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Is the extinguisher charged and inspected?
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Is fire extinguisher no more then 10 ft away?
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Working at heights
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Is permit filled out properly?
- Yes
- No
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Is proper fall-protection being used?
- Yes
- No
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Was work stopped and violation corrected?
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Has fall protection been inspected?
- Pass
- Fail
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Does the fall protection fit properly?
- Yes
- No
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Is employee tied off to proper tie off point?
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Description of task. (Detailed)
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Proper PPE being used for task?
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What special PPE is required?
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Was work stopped and corrective action taken?
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Why Not?
Tools
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Was proper tools being used for task?
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Power tools being used?
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Are all guards and handles in place?
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Are tools in good working condition?
Work area conditions
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Proper lighting for task?
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Is area clear of any trip ,slips or fall hazards?
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was work stopped and corrective action taken?
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Why Not?
General Housekeeping
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Is all walk ways free of trip hazards
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What action was taken
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Is housekeeping being performed trough out the day?
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Is all scrap material being removed and properly disposed of?
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Is there designated bins for Wood, Trash, and Metal?
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Are the bins clearly marked with material only signs?
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Is location of bins being communicated?
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Is all food and beverage containers being properly disposed of?
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A clean house is a safe house. What can we do to?
Employee feedback
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Employees thoughts and ideals to improve the safety program on site.
