• Select date

  • Add location

JSA/JHA

  • Appropriate for Task/Task Covered

  • Reviewed

  • Signed

  • Explain any infraction

Environmental/Emergency Response

  • Emergency Action plan in place

  • Has the plan been reviewed by the entire crew?

  • Spill Response Kit is available when refueling equipment.

  • First-Aid Kit

  • Explain Any Infraction

Hazardous Communication

  • MSDS Available

  • MSDS Reviewed

  • Containers Labeled Properly

  • Handling Procedures Followed

  • Explain Any Infraction

Hygiene

  • Restrooms

  • Potable Water Available

  • Cleanliness:

  • Adequate Drinking Water for Employee Hydration

  • Washing Facilities

  • Explain Any Infraction

PPE

  • Add media

  • Eye/Face

  • Hard Hat

  • Hand

  • Hearing

  • Footwear

  • Hi-Vis Vest

  • Respirator

  • Respiratory Program in Place (MEQ, Fit Test, Training, etc...)

  • FRC

  • Monitors Available, In Use, Calibrated (4-Gas, H2S or Other)

  • US Coast Guard approved flotation device

  • Explain Any Infraction

Material Handling

  • Body Mechanics

  • Safety Latch

  • Manual Lifting Devices (Come-a-Longs, Chain falls, etc…)

  • Add media

  • Slings

  • Hooks & Shackles

  • Wire Rope

  • Lifting Chains

  • Load Secure, Rigged Properly

  • Tag Lines Used

  • Other:

  • Explain any infraction

Vehicle/Equipment/Crane

  • Authorized/Qualified Operator

  • Designated Signal Person

  • Seatbelt Used

  • Backup Alarm

  • Hand Signal Chart

  • Daily/Weekly/Annual Inspection

  • Inspection Completed Properly

  • Other:

  • Explain any infraction

Material Storage

  • Material Stored Properly

  • Flammable/Combustible Storage

  • Pipe Chocked

  • Other:

  • Explain any infraction

Fall Prevention/Protection

  • Access/Egress

  • Fall Protection

  • Fall Protection Inspected

  • Scaffolds/Ladders - Proper Type

  • Scaffolds/Ladders - Inspected

  • Scaffolds/Ladders - Use

  • Handrails

  • Explain any infraction

Hand Tools

  • Condition

  • Guards/Handles

  • Add media

  • Proper for Job/Use

  • Explain any infraction

Electrical

  • GFCI/Assured Grounding Program

  • Cords/Tools – Inspected

  • Explain any infraction

Hot Work

  • Permit

  • Permit Conditions Followed

  • Fire Watch

  • Add media

  • Gas Cylinder Management

  • Add media

  • Leads/Hoses/Gauges

  • Other:

  • Explain any infraction

Fire Protection & Prevention

  • Fire Suppression Equipment

  • Annual/Monthly Fire Extinguisher Inspection

  • Properly Rated/Size (BC versus ABC)

  • Add media

  • Combustible/Flammable Material Away from Hot Work

  • Explain any infraction

Excavation

  • Excavation Type:

  • Documented Inspection by Competent Person

  • Sloped Properly

  • Add media

  • Benched Properly

  • Add media

  • Trench Box/Shoring Proper

  • Add media

  • Trench Box Certifications

  • Access/Egress Points

  • Add media

  • Spoil Pile Minimum 2-Feet From Excavation

  • Add media

  • Signs, Signals & Barricades

  • Add media

  • One Call Made

  • Utilities Identified

  • Add media

  • Explain any infraction

Signs/Barricades

  • Condition

  • Add media

  • Proper Type

  • Add media

  • Marking Hazards

  • Add media

  • Explain any infraction

Housekeeping

  • Trash

  • Add media

  • Trash Receptacles

  • Add media

  • Crew Trucks/Trailers

  • Add media

  • Explain any infraction

Walking Surfaces

  • Holes Guarded

  • Pathways

  • Trip Hazards

  • Add media

  • Explain any infraction

Traffic Control

  • Designated Flagger

  • Add media

  • Signs Posted per MUTCD

  • Add media

  • Escort Required/Used

  • Add media

  • Explain any infraction

Overhead Power Lines

  • Power Lines Marked with Goal Post and Signs

  • Designated Spotter

  • Proper Equipment for Spotter (Air Horn, Vest, etc…)

  • Explain any infraction

Radiation Sources

  • Type:

  • Signs, Signals & Barricades

  • Add media

  • Film Badges for X-Ray Crew

  • Explain any infraction

Pressure Testing

  • Equipment Integrity

  • Whip Checks/Connections Pinned

  • Signs, Signals & Barricades

  • Add media

  • Explain any infraction

Lock-Out/Tag-Out

  • Isolated

  • Potential Energy Sources Identified

  • Add location
  • Add location
  • Add location
  • Add location
  • Add location
  • Add location
  • Add location
  • Add location
  • Add location
  • Add location
  • Type of Isolation:

  • Add media

  • Verified

  • Add signature

  • Affected Personnel Informed

  • Explain any infraction

Abrasive Blasting

  • Trap and Carbon Filter Installed

  • CO Alarm in use

  • Dead-Man Switch Operable

  • Proper PPE

Confined Space

  • Permitted

  • Personnel Trained

  • Emergency Rescue Plan

  • Rescue/Retrieval Equipment (Anklets, Harness, Life Line, etc...…)

  • Explain any infraction

Signatures

  • Safety Coach

  • Signature

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