Safety Assessment

• Prepared By & Title

• Site

  Select

• Client

• Conducted On (Date)

  Date
• Location
  Address

• Subcontractors On Site

• Personnel (# & Type)

• Hardhats worn by all personnel with Name on front and back.

  OK

  At Risk

  N/A

• Eye protection & used by all personnel

  OK

  At Risk

  N/A

• Hearing protection & used by all personnel

  OK

  At Risk

  N/A

• Proper safety toe shoes

  OK

  At Risk

  N/A

• Proper Clothing (Hi-Viz upper garment, Long pants - no rips/tears)

  OK

  At Risk

  N/A

• Appropriate cut resistant gloves

  OK

  At Risk

  N/A

• Fall protection in use

  OK

  At Risk

  N/A

• Respirators/Facemasks in good condition & use as required (medical evaluation & fit test)

  OK

  At Risk

  N/A

Tools & Equipment

• Daily equipment inspection completed

  OK

  At Risk

  N/A

• Fire extinguisher mounted & in good condition

  OK

  At Risk

  N/A

• Seatbelt worn during operation

  OK

  At Risk

  N/A

• Back up alarm operable & the guide is used

  OK

  At Risk

  N/A

• Make sure all straps & rigging are free of frays and damage

  OK

  At Risk

  N/A

• Use all small tools & equipment to manufacturers specifications (i.e. ladders, cut off saws, etc.)

  OK

  At Risk

  N/A

Hazardous Chemicals/Air Contaminants

• List of hazardous materials on job (Completed on JSA)

  OK

  At Risk

  N/A

• Material safety data sheets(Black SDS Binder)

  OK

  At Risk

  N/A

• Proper containers in use with correct labels

  OK

  At Risk

  N/A

• Spill kit onsite

  OK

  At Risk

  N/A

• Blood borne pathogen kit on site

  OK

  At Risk

  N/A

General

• Proper ergonomics in use

  OK

  At Risk

  N/A

• Safe access to work area

  OK

  At Risk

  N/A

• Good housekeeping & material storage

  OK

  At Risk

  N/A

• Barricades debris protecting warning signs in place

  OK

  At Risk

  N/A

• Excavation/trenched properly protected

  OK

  At Risk

  N/A

• Shoring properly installed: Engineers stamp on drawings

  OK

  At Risk

  N/A

• Eye wash available

  OK

  At Risk

  N/A

• First Aid Kit vailable

  OK

  At Risk

  N/A

• Fire extinguisher: Good condition: Current inspection tag

  OK

  At Risk

  N/A

• Trucks: Safe/good condition

  OK

  At Risk

  N/A

• Trucks/Trailers: DOT annual inspection

  OK

  At Risk

  N/A

• Trucks/Trailers: Materials sucured properly for transportation (proper chains & binders)

  OK

  At Risk

  N/A

• All materials/implements on site staged & barricaded properly

  OK

  At Risk

  N/A

• Trailers properly chocked when on site

  OK

  At Risk

  N/A

• All personnel aware of AED location

  OK

  At Risk

  N/A

Other Paperwork & Documents

• Substation Safety Orientation Flip Book

  OK

  At Risk

  N/A

• OSHA 30/10 Sign Off Sheet signed (in jobsite binder)

  OK

  At Risk

  N/A

• Emergency phone number card (in job binder)

  OK

  At Risk

  N/A

• Daily JSA reviewed & signed (in jobsite binder)

  OK

  At Risk

  N/A

• SWPPP inspection/documented (in jobsite binder)

  OK

  At Risk

  N/A

• Terra5 Safety sheet sign off (in jobsite binder)

  OK

  At Risk

  N/A

• SSSP reviewed & singed off (in jobsite binder)

  OK

  At Risk

  N/A

• Ameren Substation Standards (Red Binder)

  OK

  At Risk

  N/A

• Terra5 Quality Control & Safety Manual (Blue Binder)

  OK

  At Risk

  N/A

• Name

• Signature

  Sign

• Date/Time Stamp

  Date