Title Page

  • Document Nr.

  • Customer / Site

  • Location
  • Executed on

  • Performed by

  • Task being observed

  • Involved personnel

BODY POSITION

  • BODY MECHANICS: Close to load, proper lifting, squared up to task (no twisting), using mechanical lift if possible, assisted if too heavy.

  • ASCEND/DESCENS: 3 points of contact.

  • PINCH POINTS: Body parts kept clear from crush point, pinch points, and cuts.

  • EYES ON TASK: Face/head in direction of travel. Watch hands engaged in tasks.

  • LINE OF FIRE: Not working/standing in path of equipment/materials that may shift, relieve pressure, move, or fall.

  • OVEREXTENDED/CRAMPED: Overextending to pass materials/working in cluttered cramped areas that limit movement.

  • STAY TO RIGHT: When passing material take one step to the right of personbelow

TOOLS & EQUIPMENT

  • TOOL SELECTION/USE: Right tool used in the manner intended.

  • TOOL CONDITION: Tools inworking order.

  • TOOLS INSPECTION: Color coede as per quarter.

  • EQUIPMENT SELECTION/USE: guards in place, de-energized for maintenance.

  • EQUIPMENT CONDITION: Electrical cords fray free.

PERSONAL PROTECTIVE EQUIPMENT

  • RESPIRATORY PROTECTION: Selection, condition, and use of respirator

  • FIT TEST: Respirator fit test completed if required.

  • EYE PROTECTION: Proper eye/face protection present and in use.

  • HAND PROTECTION: Proper hand/arm protection present and in use.

  • HEARING PROTECTION: Hearing protection in use - Double hearing protection in use if required.

  • PROTECTIVE CLOTHING: Proper protective clothing in use (FRC, Latex suit, life vests, etc.).

  • FOOT PROTECTION: Proper footwear worn.

  • HEAD PROTECTION: Proper use of hard hat (bib forward).

  • HARNESS: Proper wear/use of harness.

  • LANYARD SELECTION: Proper lanyard selection for the job (retractable, 6ft lifeline, etc.).

  • LANYARD USE: Proper wear/use of lanyard.

  • ANCHOR POINT: Tied off to suitable anchor.

NRTR / JSP / JOB PLAN

  • NRTR / JSP COMPLETED: All components of the NRTR / JSP completed prior to starting work.

  • WORKPLACE DESIGN: Is jobsite designed to prevent possible contact with hazards.

  • MAJOR STEPS OF TASK: Key steps of the task noted on NRTR / JSP.

  • HAZARD IDENTIFIED: Are hazards identified and noted on NRTR.

  • AREA-SPECIFIC HAZARDS: Are area specific hazards identified.

  • SAFE PLAN OF ACTION: Safe work plan developed to avoid and minimize exposure to risk.

  • SIGNED BY SUPERVISOR: Supervisor signed NRTR / JSP within first hour of work starting.

  • SIGNED BY CREW: All crew members signed NRTR / JSP prior to starting work

ENVIRONMENT

  • WALKING SURFACES: Walking surfaces free of hazards.

  • WORKING SURFACES: Working surface free of hazards.

  • ADEQUATE ILLUMINATION: Adequate lighti g for the work being performed.

  • HOUSEKEEPING: Proper housekeeping.

  • STORAGE: Storage area neat and orderly.

PROCEDURE RELATED

  • COMMUNICATION OF HAZARDS: All known hazards communicated prior to starting.

  • CONFINED SPACE: Confined space procedure followed.

  • LOTO: Lock-Out / Tag-Out procedure followed.

MOBILE EQUIPMENT OPERATION

  • FORKLIFT DAILY INSPECTION: Inspection completed and documented.

  • FORKLIFT CERTIFICATION: Driver has current forklift certification.

  • SEAT BELTS: Driver (and passengers) wearing seatbelt(s).

ADDITIONAL COMMENTS

  • Comments and/or remarks.

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.