Title Page
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Conducted on
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Prepared by
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Location
General Worksite
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Are Walkways Clean and Clear?
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Is there proper lighting?
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Is the work area clear of tripping hazards/obstructions?
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Appropriate trash cans and disposal locations?
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Proper containment of fluids?
Hazard Identification
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JSA completed and reviewed before the start of work?
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Did the whole crew participate in completing the JSA and sign off?
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Was JSA modified when a change occurred (weather. personnel, work tasks)?
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Task steps are written out to perform the job? Include site-specific considerations?
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Hazards identified and addressed?
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Workers following the written steps or procedure?
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Are workers aware of the "Stop Work Authority?"
Behavior-Based Safety
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Are Observations being conducted?
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Is feedback given after Observation?
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Observation Data communicated?
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Observation Data collected/analyzed/used to correct at-risk behaviors or conditions?
Fall Protection
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Fall Protection Equipment inspected and in good condition?
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Fall Protection Equipment is properly worn?
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Properly secured to an adequate Anchor Point?
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Fall distance VS Lanyard Length?
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Is proper Rescue Equipment available?
Electrical Safety
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GFCIs utilized?
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Power cords in good condition?
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Are power outlets overloaded?
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Are Electrical Panels/Boxes closed?
Personal Protective Equipment (PPE)
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Head?
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Hand?
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Task-appropriate gloves?
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Eye?
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Foot?
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Hearing?
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Body (if required)?
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Respiratory (if required)?
Manual and Power Hand Tools
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Are defective tools in use?
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Are power tool cords in good condition?
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Are power tools grounded or double insulated?
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Are guards in place?
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Are appropriate tools being used?
Powered Industrial Trucks (Forklifts)
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Appropriate speeds being used?
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Do Operators conduct a walk-around hazard assessment before moving the vehicle?
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Are Operators trained and authorized?
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Are Backup Alarms operational?
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Do Operators sound horn appropriately?
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Do Operators maintain control of their loads?
Cranes
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Are Operators trained and authorized?
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Proper Rigging used for each load?
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Rigging inspected prior to use?
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Are Taglines being used?
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Good communication between Operator and Signalman (if used)?
Welding and Cutting
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Electric Welders grounded?
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Are Cables/Hoses/Fittings serviceable and in good condition?
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Gas cylinders upright/secure?
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Are flashback preventers in place?
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Fire Extinguisher nearby?
Material Storage
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Materials are securely stacked/stored?
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Clear access to materials?
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Load rating for shelves?
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Shelving stable?
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Storage area kept neat and orderly?
Emergency Systems
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Emergency Response Plan?
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Rescue Equipment?
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First Aid Boxes stocked?
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Eyewash Stations clean and ready for use?
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Fire Extinguishers in date and readily accessible?
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Evacuation procedure?
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Are workers familiar with alarms and emergency notification procedure?
Ladders/Safe Access
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Ladders in good condition?
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Ladders inspected prior to use?
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Ladders properly set and secured?
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Three points of contact maintained on ladders?
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Adequate access?
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Handrails on walkways/stairs/ramps?
HazCom
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Are chemicals being used?
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SDS available?
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Appropriate labeling system?
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Appropriate handling of chemicals?
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Chemicals being stored properly?
Environmental Protection
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Permit compliance?
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Pollution prevention?
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Waste Management?