Safety Coach/Coordinator

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Select date

  Date
• Add location
  Address

JSA/JHA

• Appropriate for Task/Task Covered

  Yes

  No

  N/A

• Reviewed

  Yes

  No

  N/A

• Signed

  Yes

  No

  N/A

• Explain any infraction

Environmental/Emergency Response

• Emergency Action plan in place

  Yes

  No

  N/A

• Has the plan been reviewed by the entire crew?

  Yes

  No

  N/A

• Spill Response Kit is available when refueling equipment.

  Yes

  No

  N/A

• First-Aid Kit

  Yes

  No

  N/A

• Explain Any Infraction

Hazardous Communication

• MSDS Available

  Yes

  No

  N/A

• MSDS Reviewed

  Yes

  No

  N/A

• Containers Labeled Properly

  Yes

  No

  N/A

• Handling Procedures Followed

  Yes

  No

  N/A

• Explain Any Infraction

Hygiene

• Restrooms

  Yes

  No

  N/A

• Potable Water Available

  Yes

  No

  N/A

• Cleanliness:

  Media

• Adequate Drinking Water for Employee Hydration

  Yes

  No

  N/A

• Washing Facilities

  Yes

  No

  N/A

• Explain Any Infraction

PPE

• Add media

  Media

• Eye/Face

  Yes

  No

  N/A

• Hard Hat

  Yes

  No

  N/A

• Hand

  Yes

  No

  N/A

• Hearing

  Yes

  No

  N/A

• Footwear

  Yes

  No

  N/A

• Hi-Vis Vest

  Yes

  No

  N/A

• Respirator

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• FRC

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• US Coast Guard approved flotation device

  Yes

  No

  N/A

• Explain Any Infraction

  Yes

  No

  N/A

Material Handling

• Body Mechanics

  Yes

  No

  N/A

• Safety Latch

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Add media

  Media

• Slings

  Yes

  No

  N/A

• Hooks & Shackles

  Yes

  No

  N/A

• Wire Rope

  Yes

  No

  N/A

• Lifting Chains

  Yes

  No

  N/A

• Load Secure, Rigged Properly

  Yes

  No

  N/A

• Tag Lines Used

  Yes

  No

  N/A

• Other:

  Yes

  No

  N/A

• Explain any infraction

Vehicle/Equipment/Crane

• Authorized/Qualified Operator

  Yes

  No

  N/A

• Designated Signal Person

  Yes

  No

  N/A

• Seatbelt Used

  Yes

  No

  N/A

• Backup Alarm

  Yes

  No

  N/A

• Hand Signal Chart

  Yes

  No

  N/A

• Daily/Weekly/Annual Inspection

  Yes

  No

  N/A

• Inspection Completed Properly

  Yes

  No

  N/A

• Other:

  Yes

  No

  N/A

• Explain any infraction

Material Storage

• Material Stored Properly

  Yes

  No

  N/A

• Flammable/Combustible Storage

  Yes

  No

  N/A

• Pipe Chocked

  Yes

  No

  N/A

• Other:

  Yes

  No

  N/A

• Explain any infraction

Fall Prevention/Protection

• Access/Egress

  Yes

  No

  N/A

• Fall Protection

  Yes

  No

  N/A

• Fall Protection Inspected

  Yes

  No

  N/A

• Scaffolds/Ladders - Proper Type

  Yes

  No

  N/A

• Scaffolds/Ladders - Inspected

  Yes

  No

  N/A

• Scaffolds/Ladders - Use

  Yes

  No

  N/A

• Handrails

  Yes

  No

  N/A

• Explain any infraction

Hand Tools

• Condition

  Yes

  No

  N/A

• Guards/Handles

  Yes

  No

  N/A

• Add media

  Media

• Proper for Job/Use

  Yes

  No

  N/A

• Explain any infraction

Electrical

• GFCI/Assured Grounding Program

  Yes

  No

  N/A

• Cords/Tools – Inspected

  Yes

  No

  N/A

• Explain any infraction

Hot Work

• Permit

  Yes

  No

  N/A

• Permit Conditions Followed

  Yes

  No

  N/A

• Fire Watch

  Yes

  No

  N/A

• Add media

  Media

• Gas Cylinder Management

  Yes

  No

  N/A

• Add media

  Media

• Leads/Hoses/Gauges

  Yes

  No

  N/A

• Other:

  Yes

  No

  N/A

• Explain any infraction

Fire Protection & Prevention

• Fire Suppression Equipment

  Yes

  No

  N/A

• Annual/Monthly Fire Extinguisher Inspection

  Yes

  No

  N/A

• Properly Rated/Size (BC versus ABC)

  Yes

  No

  N/A

• Add media

  Media

• Combustible/Flammable Material Away from Hot Work

  Yes

  No

  N/A

• Explain any infraction

Excavation

• Excavation Type:

  Stable Rock

  Type A

  Type B

  Type C

• Documented Inspection by Competent Person

  Yes

  No

  N/A

• Sloped Properly

  Yes

  No

  N/A

• Add media

  Media

• Benched Properly

  Yes

  No

  N/A

• Add media

  Media

• Trench Box/Shoring Proper

  Yes

  No

  N/A

• Add media

  Media

• Trench Box Certifications

  Yes

  No

  N/A

• Access/Egress Points

  Yes

  No

  N/A

• Add media

  Media

• Spoil Pile Minimum 2-Feet From Excavation

  Yes

  No

  N/A

• Add media

  Media

• Signs, Signals & Barricades

  Yes

  No

  N/A

• Add media

  Media

• One Call Made

  Yes

  No

  N/A

• Utilities Identified

  Yes

  No

  N/A

• Add media

  Media

• Explain any infraction

Signs/Barricades

• Condition

  Yes

  No

  N/A

• Add media

  Media

• Proper Type

  Yes

  No

  N/A

• Add media

  Media

• Marking Hazards

  Yes

  No

  N/A

• Add media

  Media

• Explain any infraction

Housekeeping

• Trash

  Yes

  No

  N/A

• Add media

  Media

• Trash Receptacles

  Yes

  No

  N/A

• Add media

  Media

• Crew Trucks/Trailers

  Yes

  No

  N/A

• Add media

  Media

• Explain any infraction

Walking Surfaces

• Holes Guarded

  Yes

  No

  N/A

• Pathways

  Yes

  No

  N/A

• Trip Hazards

  Yes

  No

  N/A

• Add media

  Media

• Explain any infraction

Traffic Control

• Designated Flagger

  Yes

  No

  N/A

• Add media

  Media

• Signs Posted per MUTCD

  Yes

  No

  N/A

• Add media

  Media

• Escort Required/Used

  Yes

  No

  N/A

• Add media

  Media

• Explain any infraction

Overhead Power Lines

• Power Lines Marked with Goal Post and Signs

  Yes

  No

  N/A

• Designated Spotter

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Explain any infraction

Radiation Sources

• Type:

  Yes

  No

  N/A

• Signs, Signals & Barricades

  Yes

  No

  N/A

• Add media

  Media

• Film Badges for X-Ray Crew

  Yes

  No

  N/A

• Explain any infraction

Pressure Testing

• Equipment Integrity

  Yes

  No

  N/A

• Whip Checks/Connections Pinned

  Yes

  No

  N/A

• Signs, Signals & Barricades

  Yes

  No

  N/A

• Add media

  Media

• Explain any infraction

Lock-Out/Tag-Out

• Isolated

  Yes

  No

  N/A

• Potential Energy Sources Identified

  Yes

  No

  N/A
• Add location
  Address
• Add location
  Address
• Add location
  Address
• Add location
  Address
• Add location
  Address
• Add location
  Address
• Add location
  Address
• Add location
  Address
• Add location
  Address
• Add location
  Address

• Type of Isolation:

  Yes

  No

  N/A

• Add media

  Media

• Verified

  Yes

  No

  N/A

• Add signature

  Sign

• Affected Personnel Informed

  Yes

  No

  N/A

• Explain any infraction

Abrasive Blasting

• Trap and Carbon Filter Installed

  Yes

  No

  N/A

• CO Alarm in use

  Yes

  No

  N/A

• Dead-Man Switch Operable

  Yes

  No

  N/A

• Proper PPE

  Yes

  No

  N/A

Confined Space

• Permitted

  Yes

  No

  N/A

• Personnel Trained

  Yes

  No

  N/A

• Emergency Rescue Plan

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Explain any infraction

Signatures

• Safety Coach

  Sign

• Signature

  Drawing