Information
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Document No.
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Conducted on
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Prepared by
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Location
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Personnel
Leader Completing
Job Name
Job Number
Jobsite Foreman/Leader
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Site Administration & Conditions
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Accident investigation kit completed / emergency plan posted
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Current regulatory posters posted
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MSDS kit on site
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First Aid kit(s) available and properly stocked
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Fire extinguishers available, with current inspection
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Appropriate storage for flammable materials
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Housekeeping / environmental conditions
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Personal Protective Equipment
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Eye / Face Protection
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Proper Glove usage
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Hand protection
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Hearing Protection <br>
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Safety toed shoes
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Other PPE Needs (respiratory protection, proper clothing, etc)
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Tools & Equipment
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Assured grounding
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Extension cords
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Power / hand tools
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Ladders
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Electrical
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Temporary service
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GFCI testing
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Temporary lighting
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Lockout / Tagout
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Live work (training, permits, PPE)
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Elevated Work / Fall Protection
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Proper Fall Protection utilized and inspected
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Railings on stairs
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Railings on platforms higher than 6 ft.
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Aerial lifts
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Other Safety Items
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Motorized equipment inspected
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Scaffolding usage
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Proper material & wire storage
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Site access / lighting
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Jobsite Safety Discussion *Attach a copy of the Tool Box Talk / Daily Hazard Analysis to this form
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Ask the question - "If an accident were to happen today, what would it be and who would be involved?"
Who answered the question?
What was their response?
What follow up action did you take?
When was the follow up action communicated back to the employee who answered the question?
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Same Day
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Next Day
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Other
