Title Page

  • Conducted on

  • Prepared by

  • Location

General Worksite

  • Are Walkways Clean and Clear?

  • Is there proper lighting?

  • Is the work area clear of tripping hazards/obstructions?

  • Appropriate trash cans and disposal locations?

  • Proper containment of fluids?

Hazard Identification

  • JSA completed and reviewed before the start of work?

  • Did the whole crew participate in completing the JSA and sign off?

  • Was JSA modified when a change occurred (weather. personnel, work tasks)?

  • Task steps are written out to perform the job? Include site-specific considerations?

  • Hazards identified and addressed?

  • Workers following the written steps or procedure?

  • Are workers aware of the "Stop Work Authority?"

Behavior-Based Safety

  • Are Observations being conducted?

  • Is feedback given after Observation?

  • Observation Data communicated?

  • Observation Data collected/analyzed/used to correct at-risk behaviors or conditions?

Fall Protection

  • Fall Protection Equipment inspected and in good condition?

  • Fall Protection Equipment is properly worn?

  • Properly secured to an adequate Anchor Point?

  • Fall distance VS Lanyard Length?

  • Is proper Rescue Equipment available?

Electrical Safety

  • GFCIs utilized?

  • Power cords in good condition?

  • Are power outlets overloaded?

  • Are Electrical Panels/Boxes closed?

Personal Protective Equipment (PPE)

  • Head?

  • Hand?

  • Task-appropriate gloves?

  • Eye?

  • Foot?

  • Hearing?

  • Body (if required)?

  • Respiratory (if required)?

Manual and Power Hand Tools

  • Are defective tools in use?

  • Are power tool cords in good condition?

  • Are power tools grounded or double insulated?

  • Are guards in place?

  • Are appropriate tools being used?

Powered Industrial Trucks (Forklifts)

  • Appropriate speeds being used?

  • Do Operators conduct a walk-around hazard assessment before moving the vehicle?

  • Are Operators trained and authorized?

  • Are Backup Alarms operational?

  • Do Operators sound horn appropriately?

  • Do Operators maintain control of their loads?


  • Are Operators trained and authorized?

  • Proper Rigging used for each load?

  • Rigging inspected prior to use?

  • Are Taglines being used?

  • Good communication between Operator and Signalman (if used)?

Welding and Cutting

  • Electric Welders grounded?

  • Are Cables/Hoses/Fittings serviceable and in good condition?

  • Gas cylinders upright/secure?

  • Are flashback preventers in place?

  • Fire Extinguisher nearby?

Material Storage

  • Materials are securely stacked/stored?

  • Clear access to materials?

  • Load rating for shelves?

  • Shelving stable?

  • Storage area kept neat and orderly?

Emergency Systems

  • Emergency Response Plan?

  • Rescue Equipment?

  • First Aid Boxes stocked?

  • Eyewash Stations clean and ready for use?

  • Fire Extinguishers in date and readily accessible?

  • Evacuation procedure?

  • Are workers familiar with alarms and emergency notification procedure?

Ladders/Safe Access

  • Ladders in good condition?

  • Ladders inspected prior to use?

  • Ladders properly set and secured?

  • Three points of contact maintained on ladders?

  • Adequate access?

  • Handrails on walkways/stairs/ramps?


  • Are chemicals being used?

  • SDS available?

  • Appropriate labeling system?

  • Appropriate handling of chemicals?

  • Chemicals being stored properly?

Environmental Protection

  • Permit compliance?

  • Pollution prevention?

  • Waste Management?

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.