SAI RISK ANALYSIS/SITE INSPECTION FORM

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Weather

• Sunny

  Cloudy

  Rain

  Snow

  Sleet

Work Description

• Comment

Contractor

• Comment

#1 Personal Protection Equipment (PPE)

• Hard Hat

  Safe

  At Risk

  N/A

• Clothing Protection

  Safe

  At Risk

  N/A

• Foot Protection

  Safe

  At Risk

  N/A

• Work Gloves

  Safe

  At Risk

  N/A

• Fall Protection

  Safe

  At Risk

  N/A

• Vest

  Safe

  At Risk

  N/A

• Ear Protection

  Safe

  At Risk

  N/A

• Rubber Gloves

  Safe

  At Risk

  N/A

• Respiratory Protection

  Safe

  At Risk

  N/A

• HazMat Protection

  Safe

  At Risk

  N/A

#2 PPE Work Envoronment

• Access Road

  Safe

  At Risk

  N/A

• Congested Site

  Safe

  At Risk

  N/A

• Fall Hazards

  Safe

  At Risk

  N/A

• Elec / RF Clearance

  Safe

  At Risk

  N/A

• Excavation Hazards

  Safe

  At Risk

  N/A

• Crane Cleareness

  Safe

  At Risk

  N/A

• Housekeeping

  Safe

  At Risk

  N/A

• Slip, Trip, or Fall

  Safe

  At Risk

  N/A

• HazMat Abatement

  Safe

  At Risk

  N/A

• Public Way Traffic

  Safe

  At Risk

  N/A

#3 PPE Procedures

• Excavation

  Safe

  At Risk

  N/A

• Conc. Form/Pouring

  Safe

  At Risk

  N/A

• Tower/Pole Stacking

  Safe

  At Risk

  N/A

• Climbing

  Safe

  At Risk

  N/A

• Electrical Work

  Safe

  At Risk

  N/A

• Coax Work

  Safe

  At Risk

  N/A

• Man-Lift

  Safe

  At Risk

  N/A

• Crane Picks

  Safe

  At Risk

  N/A

#4 PPE Site Protection

• Police Detail

  Safe

  At Risk

  N/A

• Signs/Flags/Cones

  Safe

  At Risk

  N/A

• Excavation Barricades

  Safe

  At Risk

  N/A

• Work Area Barricades

  Safe

  At Risk

  N/A

• Materials Staging

  Safe

  At Risk

  N/A

• Holes Covered

  Safe

  At Risk

  N/A

• Silt Fence/Hay Bales

  Safe

  At Risk

  N/A

#5 PPE Individuals Work

• Lifting / Carrying

  Safe

  At Risk

  N/A

• Climbing

  Safe

  At Risk

  N/A

• Working Aoft

  Safe

  At Risk

  N/A

• Loading Rigging

  Safe

  At Risk

  N/A

• Tool Usage

  Safe

  At Risk

  N/A

#6 PPE Interior Facilties

• Parking / Walking

  Safe

  At Risk

  N/A

• Toilet

  Safe

  At Risk

  N/A

• First Aid

  Safe

  At Risk

  N/A

• Fire Extinguisher(s)

  Safe

  At Risk

  N/A

• Lighting

  Safe

  At Risk

  N/A

• Eye Wash

  Safe

  At Risk

  N/A

#7 PPE Tools & Eqpt

• All Electrical Circuits GFCI

  Safe

  At Risk

  N/A

• Temp Electric Cords

  Safe

  At Risk

  N/A

• Hand Tools

  Safe

  At Risk

  N/A

• Power Tools

  Safe

  At Risk

  N/A

• Extension Cords

  Safe

  At Risk

  N/A

• Coax Tools

  Safe

  At Risk

  N/A

• Rigging Equipment

  Safe

  At Risk

  N/A

• Power Capstan

  Safe

  At Risk

  N/A

#8 PPE Vehicles

• First Aid Kit

  Safe

  At Risk

  N/A

• Fire Extiguisher

  Safe

  At Risk

  N/A

• Housekeeper

  Safe

  At Risk

  N/A

• Seat Belts in Use

  Safe

  At Risk

  N/A

• Properly Positioned

  Safe

  At Risk

  N/A

• Wheels Chocks

  Safe

  At Risk

  N/A

• Traffic Cones

  Safe

  At Risk

  N/A

• Emergency Break Set

  Safe

  At Risk

  N/A

#9 PPE