Safety Assessment

Information

• Inspector Name

• Position

• Site Visited
  Address

• Date

  Date

• Check Box if non-compliant

Personal Protective Equipment As Required

• Hard Hat

• Explain

• Safety Glasses and/or Face Shield

• Explain

• Hearing Protection

• Explain

• Respiratory Protection

• Explain

• Gloves

• Explain

• Boots for the Task

• Explain

• Chaps

• Explain

• Sleeved Shirt & Long Pants

• Explain

• High Visibility Shirt or Vest Worn

• Explain

• Safety Vest as Required (Reflective at Night)

• Explain

Equipment

• Equipment Inspected

• Explain

• Guarding of Machine Parts

• Explain

• Horns, Lights, Back-up Alarms & Cameras Working

• Explain

• Seat Belts Worn

• Explain

• Floorboard Free of Clutter

• Explain

• Steps Clear of Debris

• Explain

Work Site

• Organized Flow

• Explain

• Standard Railing & Toe Boards Installed

• Explain

• Berms or Guard Rails in Place

• Explain

• Electrical Hazards

• Explain

• Fire Extinguishers Mounted, Available, Inspected

• Explain

• Eye Wash Stations Inspected and Clear

• Explain

• Flammable Liquids & Gasses Controlled

• Explain

• JHAs Available

• Explain

• MSDS Available

• Explain

Personal Risk Management

• Working Responding to Hazards

• Explain

• Proper Lifting

• Explain

• Worker Trained for Task

• Explain

• Works Protected from Fall Above 10 Feet

• Explain

• Repetitive Motion Hazards

• Explain

• Extreme Heat/Cold - Hydration and Breaks

• Explain

• Drug and Alcohol Free

• Explain

• Workers Protected from Open Sides 4 Feet or Greater Above Lower Surface

• Explain

Trenching Site

• 4' or 5' Deep - Egress (ladder) Within 25'

• Explain

• 5' or Deeper - Properly Sloped or Shored/Shielding & Ladder within 25'

• Explain

• Standing or Flowing Water Controlled

• Explain

• Spoil Pile Minimum of 2' Away from Trench Edge

• Explain

• Soil Classified - Visual and Manual

• Explain

• Trenching Data Available

• Explain

• Utilities Marked - Uncovered Utilities Supported

• Explain

• Workers not Exposed to Cave-in or Falling Object

• Explain

• Competent Authroity Near By

• Explain

Housekeeping

• Egress Clear

• Explain

• Slip or Trip Hazard

• Explain

• Clutter

• Explain

• Vegetation Controlled

• Explain

• Food not Consumed in Industrial Maintainence

• Explain

Employee Interview

• Safety Statement?

• Explain

• Toolbox Talk Understood?

• Explain

• Supervisory Support of Safety?

• Explain

• Unchecked Hazards?

• Explain

Reinforcement of Safety Culture

• No Findings

• Explain

- Safe and Healthful Work Site - Employee Recognized for Support of Safety

• Audit Positive Comments:

- Unsafe Task Observed - Corrective Action Taken

• Audit Corrective Comments

Driver Observations

• Driver or Unit #

• Driver is Properly Wearing Seat Belt

  Select Yes No

  • Yes
  • No

• No Evidence Driver is Using Handheld Cell Phone

  Select Yes No

  • Yes
  • No

• No Evidence Driver is Distracted by Map, Food, GPS, etc.

  Yes

  No

• Comments:

• Driver or Unit #

• Driver is Properly Wearing Seat Belt

  Select Yes No

  • Yes
  • No

• No Evidence Driver is Using Handheld Cell Phone

  Select Yes No

  • Yes
  • No

• No Evidence Driver is Distracted by Map, Food, GPS, etc.

  Select Yes No

  • Yes
  • No

• Comments:

• Driver or Unit #

• Driver is Properly Wearing Seat Belt

  Select Yes No

  • Yes
  • No

• No Evidence Driver is Using Hand Held Cell Phone

  Select Yes No

  • Yes
  • No

• No Evidence Driver is Distracted by Map, Food, GPS, etc.

  Select Yes No

  • Yes
  • No

• Comments:

Hand Safety Observations

Observation Area

• Appropriate hand protection being worn for task

  Yes

  No

• Do the gloves properly fit employee's hand

  Yes

  No

• Are cuts observed on employee hand(s)

  Yes

  No

• Comments