Safety Assessment**

• Document No.

• Crew Leader / Foreman

• Client / Site

• Weather Conditions

• Conducted on

  Date
• Location
  Address

• Prepared by

• Personnel

A. Personal Protective Equipment

• Hard Hats in use by all personnel (1=Auto Fail)<br>

  3

  2

  1

  0

• Eye protectin in use by all personnel

  3

  2

  1

  0

• Hearing protection in use when required

  3

  2

  1

  0

• Proper Foot Wear

  3

  2

  1

  0

• Proper clothing ( FR if applicable )

  3

  2

  1

  0

• Reflective vest worn by all personnel (1=Auto Fail)

  3

  2

  1

  0

• Fall protection in use

  3

  2

  1

  0

• Respirator / face mask when required

  3

  2

  1

  0

B. Tools and Equipment

• Tools and Equipment in good condition

  3

  2

  1

  0

• All equipment properly guarded

  3

  2

  1

  0

• Electrical equipment connected properly, grounded and in good condition. GFCI; automatic magnetic cut-off for woodworking tools.

  3

  2

  1

  0

• Machine guards / pinch points identified / protected

  3

  2

  1

  0

• Rigging / lifting equipment in good condition and inspected

  3

  2

  1

  0

• Ladders in good condition; tied back; extended 3 ft beyond landing

  3

  2

  1

  0

C. Heavy equipment

• Daily inspection completed

  3

  2

  1

  0

• Fire extinguisher mounted and in good condition

  3

  2

  1

  0

• Seatbelt worn during operation

  3

  2

  1

  0

• Perimeter around equipment clear

  3

  2

  1

  0

D. Work site

• Street signs erected and properly placed according to MUTCD (if signs are not out 1 applies)(1=Auto Fail)

  3

  2

  1

  0

• Safety cones in good condition and placed correctly

  3

  2

  1

  0

• Traffic taper correctly positioned

  3

  2

  1

  0

• Brakes set on truck / Chock on unhitched trailers

  3

  2

  1

  0

• Equipment properly secured on truck / trailer

  3

  2

  1

  0

E. General

• Safe access to work site

  3

  2

  1

  0

• Good housekeeping and material storage

  3

  2

  1

  0

• Barricades / Debris / Warning signs in place around pot holes

  3

  2

  1

  0

• Excavations / trenches properly protected , spoil pile 2 feet away from excavation (1= Auto fail)

  3

  2

  1

  0

• Shoring properly installed / tabulated Data on site (1=Auto Fail)

  3

  2

  1

  0

• First aid kit / Eye wash available

  3

  2

  1

  0

• Fire extinguisher: good condition; current inspection tag; within 50 ft

  3

  2

  1

  0

• Per-task cards reviewed by work crews (1=Auto Fail)

  3

  2

  1

  0

• Utilities located / properly identified (1= Auto Fail)

  3

  2

  1

  0

F. D.O.T.

• Truck inspection completed

  3

  2

  1

  0

• Lights / reflectors / beacons operational

  3

  2

  1

  0

• Truck cab neat / vehicle clean

  3

  2

  1

  0

• Trailer properly mounted and free of debris

  3

  2

  1

  0

• Tires with in acceptable tread depth

  3

  2

  1

  0

Positives and Deltas

• Posatives

• Deltas