Sample - Contractor Safety Self-Evaluation Checklist

• PWD/ROICC/OICC/FSC Office:

• Conducted on

  Date

• Final overall score (Equals lowest rating for any one category):

• Location
  Address

• Contractor

• Contract % complete:

• Total monthly man-hours:

• Contract title:

• QC Manager:

• Total cumlative man-hours:

• Superintendent:

• Person completing inspection:

• Site Safety Health Officer (SSHO):

• SSHO Level (1), (2), (3), (4), (5), or (6)

• Questions answered "NO" are to be entered into the Site Safety and Occupational Health Deficiency Tracking System for correction (Refer to EM 385-1-1 01.A.12.d)

Preparatory Phase/ORM Planning

• 1. Accepted Accident Prevention Plan (APP) on-site and updated to reflect current management?

  Yes

  No

  N/A

• 2. Applicable UFGS 013526 available in site?

  Yes

  No

  N/A

• 3. Competent Person employed full time as Site Safety and Health Officer (SSHO) unless specified differently in contract?

  Yes

  No

  N/A

• 4. SSHO on site at all times when work is being performed?

  Yes

  No

  N/A

• 5. Safety inspections/audits conducted by competent persons, of the work site, material, and equipment documented in writing and available on request?

  Yes

  No

  N/A

• 6. Safety and health bulletin board erected in area commonly accessed and in clear view of the on-site workers?

  Yes

  No

  N/A

• 7. Safety and occupational health deficiency tracking system established and updated daily (Refer EM 385-1-1 01.A12.d)?

  Yes

  No

  N/A

• 8. Qualified person conducting /documenting all training, meetings and indoctrination for new employees?

  Yes

  No

  N/A

• 9. Activity hazard analysis (AHA) with competent person identified and proof of qualifications attached and accepted by government designated authority for each work activity on site?

  Yes

  No

  N/A

• 10. Work not started until activity hazard analysis reviewed by contractor, subcontractor(s) and government on-site representatives during preparation and initial phase meeting?

  Yes

  No

  N/A

• 11. Are required weekly safety meetings for all workers to review past activities, plan for new or changed operations, review AHA's by trade, establish safe working procedures for upcoming hazards, provide safety and health training being held and documented?

  Yes

  No

  N/A

• 12. Are required monthly safety meetings for all supervisors on the project location to review past activities, plan for new or changed operations reviewed AHAs by trade, establish safe working procedures for upcoming hazards, provide safety and health training being held and documented?

  Yes

  No

  N/A

• 13. Witten hazard communication program submitted and implemented IAW EM 385-1-1 section 06.B.01?

  Yes

  No

  N/A

• 14. MSDS for each hazardous substance maintained with site map attached?

  Yes

  No

  N/A

• 15. Prime contractor assuring subcontractor compliance with requirements of EM 385-1-1?

  Yes

  No

  N/A

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Office Trailer / Signage / General

• 16. Office and storage trailers properly anchored?

  Yes

  No

  N/A

• 17. Emergency phone numbers posted?

  Yes

  No

  N/A

• 18. Temporary project fencing which extends from grade level to a minimum of 48" above grade (unless GDA determines otherwise based on risk analysis)

  Yes

  No

  N/A

• 19. Signs warning of the presence of construction hazards and requiring unauthorized persons to keep out Posted on fence every 150 feet?

  Yes

  No

  N/A

• 20. Contractor aware of immediate notification for all injuries required by PWD/ROICC/OICC/FSC Office?

  Yes

  No

  N/A

• 21. Emergency plans in case of fire or other emergency prepared in writing and reviewed?

  Yes

  No

  N/A

• 22. Drinking water with disposable cups and a waste receptacle available?

  Yes

  No

  N/A

• 23. Toilet facilities with washing facilities available?

  Yes

  No

  N/A

• 24. Highly visible map delineating best route to nearest medical facility posted on safety bulletin boards?

  Yes

  No

  N/A

• 25. First-aid kit, type III, 16 unit, and one pocket mouth piece or CPR barrier provided and maintained with inventory log available?

  Yes

  No

  N/A

• 26. All employees on site wearing as a minimum short sleeve shirt, long pants, leather or other protective work shoes or boots?

  Yes

  No

  N/A

• 27. Every floor, working place and passageway kept free from protruding nails, splinters, loose boards, clutter and unnecessary holes and openings?

  Yes

  No

  N/A

• 28. Work areas inspected daily for adequate housekeeping and recorded on daily safety inspection report?

  Yes

  No

  N/A

• 29. Traffic control around site adequate?

  Yes

  No

  N/A

• Other? Extra Credit?

  Yes

  No

  N/A

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Fire Prevention

• 30. Written fire prevention plan on site abnd used to brief employees?

  Yes

  No

  N/A

• 31. Fire extinguishers available, fully charged, easily visible within 75 for low hazard areas?

  Yes

  No

  N/A

• 32. Fire extinguishers inspected monthly, recorded on tags, and initialed?

  Yes

  No

  N/A

• 33. Fuel stored in safety cans labeled/listed and painted red with yellow band and contents indicated?

  Yes

  No

  N/A

• 34. Are hot work permits being obtained for welding, cutting, or operating other flame-producing/spark producing devices from the fire department?

  Yes

  No

  N/A

• 35. Are fire watches provided?

  Yes

  No

  N/A

• Other? Extra Credit?

  Yes

  No

  N/A

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Personal Protective Equipment (PPE)

• 36. Workers wearing safety-toed leather shoes or boots meeting ASTM F 2412-05 and F 2413-05?

  Yes

  No

  N/A

• 37. Hard hats being worn properly and meeting ANSI Z89.1?

  Yes

  No

  N/A

• 38. Are workers involved in activities that subject hands to injury using hand protection appropriate for the hazard?

  Yes

  No

  N/A

• 39. Safety glasses used where appropriate?

  Yes

  No

  N/A

• 40. Hearing protection being used where appropriate? (If you need to yell to converse, hearing protection is required)

  Yes

  No

  N/A

• 41. Workers wearing respirators where appropriate?

  Yes

  No

  N/A

• 42. Impalement protection provided where personnel could work above vertical impalement hazards (rebar, etc.)?

  Yes

  No

  N/A

• 43. Are protective leg chaps worn by workers who operate chain saws?

  Yes

  No

  N/A

• 44. High visibility vests being worn when workers are exposed to vehicular or equipment traffic at up to 45 MPH, there is limited or reduced visibility for workers around mobile/heavy equipment or workers are working close to vehicular traffic with no protective barriers?

  Yes

  No

  N/A

• Other? Extra credit?

  Yes

  No

  N/A

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Scaffold Safety

• 45. Has a site specific fall protection plan and prevention plan and AHA been accepted by the GDA prior to commencing work in elevated areas?

  Yes

  No

  N/A

• 46. All erection, moving, dismantling, or altering of scaffolds systems under the supervision of a scaffolding competent person?

  Yes

  No

  N/A

• 47. Competent person using a color-coded tagging system? (Green = Inspected & safe to use) (Red = Scaffold is unsafe to use)

  Yes

  No

  N/A

• 48. Planks overlapped not less than 6" or more than 12" over end support with toe boards in place?

  Yes

  No

  N/A

• 49. Scaffold pinned properly and all corner bracing in place?

  Yes

  No

  N/A

• 50. Scaffold height not more than 4 times smallest base dimension and system is secured to structure?

  Yes

  No

  N/A

• 51. All guardrails in place?

  Yes

  No

  N/A

• 52. Full work platform or decks at each working level with no cracks/splits?

  Yes

  No

  N/A

• 53. Work Platform or deck securely fastened to scaffold?

  Yes

  No

  N/A

• 54. Safe access provided to each working level?

  Yes

  No

  N/A

• 55. Is scaffold plumb and level?

  Yes

  No

  N/A

• 56. Suspended scaffold systems using independent personal fall arrest system?

  Yes

  No

  N/A

• 57. Personnel prohibited from riding on manually propelled scaffolds?

  Yes

  No

  N/A

• Other? Extra credit?

  Yes

  No

  N/A

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Fall Protection

• 58. Has site-specific fall protection and prevention plan been accepted?

  Yes

  No

  N/A

• 59. Workers using fall protection equipment using "Buddy System" to begin rescue of fallen worker if required?

  Yes

  No

  N/A

• 60. All workers above 6 foot fall protection threshold protected from falling to a lower level?

  Yes

  No

  N/A

• 61. Are employees trained for fall protection systems in use?

  Yes

  No

  N/A

• 62. Has the contractor designated a competent person for fall protection?

  Yes

  No

  N/A

• 63. Is a written rescue plan (IAW ANSI Z359.2) been prepared and maintained when workers are working at heights?

  Yes

  No

  N/A

• 64. Is a full body harness used?

  Yes

  No

  N/A

• 65. All workers aloft tied off at all times (100%) to structural element capable of supporting 5,000 lbs?

  Yes

  No

  N/A

• 66. Have standard guardrails been provided where needed?

  Yes

  No

  N/A

• 67. Access to work areas greater than 20 feet provided with a stair system?

  Yes

  No

  N/A

• 68. Have horizontal lifelines, if used been designed and installed under the supervision of a qualified person?

  Yes

  No

  N/A

• Other? Extra Credit?

  Yes

  No

  N/A

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Ladder Safety

• 69. Ladders extend 3 feet above landing platform and tied to structure?

  Yes

  No

  N/A

• 70. Are ladders used with hand tools only?

  Yes

  No

  N/A

• 71. Are ladder base distances from structure 1/4 height?

  Yes

  No

  N/A

• 72. Are floor openings either covered or surrounded by a guardrail?

  Yes

  No

  N/A

• 73. Electricians not using conductive ladders?

  Yes

  No

  N/A

• 74. Stairways provided on all structures over 20 feet during construction / with guardrail?

  Yes

  No

  N/A

• 75. All flights of stairs with 4 or more risersd have standard stair railings or handrails?

  Yes

  No

  N/A

• 76. Portable step ladders over 20 feet not used on the site?

  Yes

  No

  N/A

• 77. Are ladders properly used?

  Yes

  No

  N/A

• Other? Extra credit?

  Yes

  No

  N/A

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Excavations

• 78. Has excavation/trenching plan in accordance with (section 26.A.01.a-n) been submitted and been accepted by the GDA prior to beginning operations?

  Yes

  No

  N/A

• 79. Competent person able to demonstrate training, experience, and knowledge of soil analysis: protective systems and requirements of 29 CFR 1926 Subpart P and has authority to stop work when required?

  Yes

  No

  N/A

• 80. Competent person inspected and documented excavation daily?

  Yes

  No

  N/A

• 81. High visibility apparel worn by all workers exposed to vehicle traffic or working around equipment?

  Yes

  No

  N/A

• 82. Hydraulic excavators, wheel/trucks/backhoe loaders used to transport or hoist loads with rigging comply with EM 385-1-1 Section 16 "S" and have AHA specific to these operations?

  Yes

  No

  N/A

• 83. Written proof of qualification of equipment operators, riggers involved in hoisting, transporting operations?

  Yes

  No

  N/A

• 84. Operational test performed as described in EM385-1-1 Section 16.F?

  Yes

  No

  N/A

• 85. Manufactures operating manual with equipment?

  Yes

  No

  N/A

• 86. Proper use of rigging, including positive latching device?

  Yes

  No

  N/A

• 87. Inspection of rigging?

  Yes

  No

  N/A

• 88. Barricade of radius of equipment and load?

  Yes

  No

  N/A

• 89. Over 4 feet deep must have a ladder within 25 feet and two means of egress?

  Yes

  No

  N/A

• 90. Has proper slope or trench box/shoring been provided?

  Yes

  No

  N/A

• 91. Is water controlled/removed?

  Yes

  No

  N/A

• 92. Is excavated material at least 2 feet back from trench edge?

  Yes

  No

  N/A

• 93. Has safe access/protection been provided to prevent personnel, vehicles, and equipment from falling into excavations?

  Yes

  No

  N/A

• 94. Perimeter protection that meets class I or class II or class III requirements been provided?

  Yes

  No

  N/A

• Other? Extra credit?

  Yes

  No

  N/A

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Electrical

• 95. Has a sketch of temporary power distribution been submitted and accepted by the GDA?

  Yes

  No

  N/A

• 96. Electrical work performed by qualified personnel with verifiable credentials?

  Yes

  No

  N/A

• 97. Energized work permit submitted to GDA prior to any work on energized lines on equipment and IAW NFPA70E and EM 3851.E.. 02c(1)-(8)

  Yes

  No

  N/A

• 98. Are ARC flash requirements known and adhered to?

  Yes

  No

  N/A

• 99. Are temporary power panel and receptacles protected from weather?

  Yes

  No

  N/A

• 100. GFCI's in use for site tools? (Applies to existing outlets in renovation projects as well)

  Yes

  No

  N/A

• 101. Temporary lights insulated from supports properly with all lamps working and guarded?

  Yes

  No

  N/A

• 102. Overhead power lines in area, operations prohibited unless maintaining proper clearance distances?

  Yes

  No

  N/A

• 103. Has hazardous energy control program been submitted and accepted by GDA? (OLD Tock out / Tag out)

  Yes

  No

  N/A

• 104. Vertical clearance of temporary wiring of at least 10 feet maintained?

  Yes

  No

  N/A

• 105. All flexible cords inspected at least daily? Documented?

  Yes

  No

  N/A

• 108. Flexible cords not spliced except hard service cords #12 or larger with molded or vulcanized spliced by qualified electrician?

  Yes

  No

  N/A

• Other? Extra Credit?

  Yes

  No

  N/A

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Cranes

• 107. Before crane/hoisting equipment is placed in service has it been inspected, tested, and certified in writing by a competent person to be in accordance with the manufacturer's recommendations and the requirements of the EM 385?

  Yes

  No

  N/A

• 108. Crane operator designated qualified and proof of qualification in writing provided to GDA?

  Yes

  No

  N/A

• 109. Project has adequate means for monitoring local weather conditions, including a wind-indicating device?

  Yes

  No

  N/A

• 110. ARE EM385-1-1 16.D.08 (At the beginning of each shift) start up inspections performed by operator and submitted with DRI?

  Yes

  No

  N/A

• 111. Has the periodic inspection been performed prior to use on site IAW EM 385-1-1 Table 16-1 and 16.D.10?

  Yes

  No

  N/A

• 112. Is crane equipped with anti two-block device if required?

  Yes

  No

  N/A

• 113. Is the crane level and on firm ground and outriggers in use with appropriate cribbing?

  Yes

  No

  N/A

• 114. IAW 16.G.09 when cane is operated within 20 foot of power lines (operating work zone is area 360 degrees around crane) has a determination been made that all power lines are energized?

  Yes

  No

  N/A

• 115. IAW Table 16-3 crane not allowed to work closer than 10 foot of energized power lines (Depending on actual voltage of lines)

  Yes

  No

  N/A

• 116. Is crane side loading prohibited?

  Yes

  No

  N/A

• 117. are rigging cables and slings inspected by a competent person before each shift?

  Yes

  No

  N/A

• 118. Are workers protected from crane swing radius and prevented from passing under the load?

  Yes

  No

  N/A

• Other? Extra Credit?

  Yes

  No

  N/A

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Confined Space

• 119. All confined space work IAW EM 385-1-1 Section 34.A.06?

  Yes

  No

  N/A

• 120. Is confined space competent person (CSCP), in writing, identified?

  Yes

  No

  N/A

• 121. Is atmosphere being monitored?

  Yes

  No

  N/A

• 122. Is space being ventilated?

  Yes

  No

  N/A

• 123. Are entrants, attendants and entry supervisor properly trained?

  Yes

  No

  N/A

• 124. Is rescue/retrieval equipment in place for permit required confined places?

  Yes

  No

  N/A

• 125. Are entry permits posted at point of entry and signed by entry supervisor?

  Yes

  No

  N/A

• 126. Is the point of entry posted "Danger Confined Space"?

  Yes

  No

  N/A

• 127. Has blanking or locking out of systems taken place?

  Yes

  No

  N/A

• Other? Extra credit?

  Yes

  No

  N/A

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Roofing

• 128. Has structural analysis of the roof been conducted by a qualified person?

  Yes

  No

  N/A

• 129. Has competent person completed a daily inspection?

  Yes

  No

  N/A

• 130. Has competent person developed a fall protection plan, submitted/accepted by GDA?

  Yes

  No

  N/A

• 131. Are kettles at least 25 feet away from the buildings?

  Yes

  No

  N/A

• 132. Is kettle attendant wearing proper PPE at all times?

  Yes

  No

  N/A

• 133. Are two fire extinguishers at the kettle?

  Yes

  No

  N/A

• 134. Are skylights and roof penetrations covered or barricaded appropriately?

  Yes

  No

  N/A

• 135. Has the roof been evaluated for its ability to support the intended construction loads?

  Yes

  No

  N/A

• 136. If warning lines on low sloped roofs are used, are they properly installed / maintained?

  Yes

  No

  N/A

• 137. Are fuel cylinders a minimum of 10 feet from open flame?

  Yes

  No

  N/A

• Other? Extra Credit?

  Yes

  No

  N/A

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Equipment

• 138. All machinery or equipment inspected daily, when in use, by competent person?

  Yes

  No

  N/A

• 139. Are operators trained and authorized to operate powered industrial trucks (Forklifts), lift trucks, and similar equipment?

  Yes

  No

  N/A

• 140. Mobile equipment equipped with backup alarms? Rollover cages / moving parts adequately guarded?

  Yes

  No

  N/A

• 141. Are equipment operations maintained safe clearance from electrical power lines?

  Yes

  No

  N/A

• 142. Modifications meet manufacturer instructions (I.E. lifting personnel with forklift - (Not allowed by many manufacturers)?

  Yes

  No

  N/A

• 143. Are safety lashings provided for high pressure hose connections, I.E. air compressors?

  Yes

  No

  N/A

• 144. Are workers clear of blind spots associated with mobile construction equipment?

  Yes

  No

  N/A

• 145. Are daily walk around inspections of all aerial lifts performed and documented by qualified operators?

  Yes

  No

  N/A

• 146. Do aerial lifts have basket / platform with guardrail?

  Yes

  No

  N/A

• 147. Workers not extending over guardrail of aerial lifts?

  Yes

  No

  N/A

• 148. Are articulating boom platforms (JLG type) used with full body harness attached to a proper attachment points on boom or basket?

  Yes

  No

  N/A

• 149. Are dump truck checklists being used and copies kept on site?

  Yes

  No

  N/A

• 150. Inspection, maintenance, and repairs to conveyors performed IAW manufacturer's recommendations by qualified personnel?

  Yes

  No

  N/A

• 151. Exposed moving machinery parts mechanically or electrically guarded?

  Yes

  No

  N/A

• 152. When two or more conveying systems are interfaced are adequate guarding and safety devices in place?

  Yes

  No

  N/A

• Other? Extra credit?

  Yes

  No

  N/A

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Tree Maintenance and Removal

• 153. All trees maintenance or removal performed under the direction or a qualified tree worker?

  Yes

  No

  N/A

• 154. Only qualified line-clearance tree trimmer or line-clearance trainee assigned to work in close proximity to electrical hazards?

  Yes

  No

  N/A

• 155. Tree workers in a bucket or work platform using fall protection?

  Yes

  No

  N/A

• 156. All tree work operations above 12 foot have a second worker in the area?

  Yes

  No

  N/A

• 157. Prior to felling operations, has work area been cleared and escape routes planned?

  Yes

  No

  N/A

• 158. All employees working from the uphill side whenever possible?

  Yes

  No

  N/A

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Demolition

• 159. Has demolition plan, based on engineering, lead, and asbestos survey by a registered professional engineer been accepted?

  Yes

  No

  N/A

• 160. Waste not being dropped > 6 foot unless in an enclosed chute and area secured from traffic?

  Yes

  No

  N/A

• 161. For building demolition, has notification been made to state having jurisdiction?

  Yes

  No

  N/A

• 162. Are nails removed from scrap lumber / materials?

  Yes

  No

  N/A

• 163. Fragmentation of glass controlled?

  Yes

  No

  N/A

• 164. Material chutes at an angle greater than 45 degrees from the horizontal enclosed?

  Yes

  No

  N/A

• Other? Extra credit?

  Yes

  No

  N/A

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Abatement

• 165. Has abatement plan been submitted and accepted?

  Yes

  No

  N/A

• 166. Is independent air monitoring being performed as required inside and outside barriers?

  Yes

  No

  N/A

• 167. Is containment in place without integrity comprimise?

  Yes

  No

  N/A

• 168. Are employees utilizing appropriate PPE?

  Yes

  No

  N/A

• 169. If negative air is used, are fans used continuously and monitored for pressure differential?

  Yes

  No

  N/A

• 170. Has baseline been performed and necessary final clearance readings taken?

  Yes

  No

  N/A

• 171. Are inspections by independent PQP performed prior to barrier removal?

  Yes

  No

  N/A

• 172. Is waste material properly containerized and stored?

  Yes

  No

  N/A

• 173. Are air monitoring results provided to GDA?

  Yes

  No

  N/A

• 174. Are waste shipment records provided to GDA?

  Yes

  No

  N/A

• Other? Extra Credit?

  Yes

  No

  N/A

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Waterfront Activities

• 175. Work over or near water and the distance to water surface is less than 25 feet or more and water depth is less than 10 feet are fall protection requirements followed? (PFDs not required)

  Yes

  No

  N/A

• 176. Work over or near water and the distance to water surface is 25 feet or more are fall protection requirements followed?

  Yes

  No

  N/A

• 177. Marine fall protection railing type A or type B provided for vessel decks 6 feet or more above adjacent decks, docks, or other hard surfaces?

  Yes

  No

  N/A

• 178. PFD's worn by personnel in areas where deck perimeter is not present?

  Yes

  No

  N/A

• 179. Is a rescue skiff available?

  Yes

  No

  N/A

• 180. Are emergency life rings available?

  Yes

  No

  N/A

• 181. If diving operations are taking place, has a dive plan been submitted and accepted by the DDC?

  Yes

  No

  N/A

• 182. If diving, is first-aid kit, oxygen resuscitation system (30 minute supply), and a stokes litter or backboard with floatation capability on site?

  Yes

  No

  N/A

• 183. Does dive team consist of proper number and qualifications for employees?

  Yes

  No

  N/A

• 184. Hand rails used for fall protection on all marine vessels for contracts awarded since March 2007

  Yes

  No

  N/A

• 185. Marine (vessel) decks 6 feet or more above other surfaces have type A or type B fall protection provided?

  Yes

  No

  N/A

• Other? Extra credit?

  Yes

  No

  N/A

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Scoring:

• Total applicable for each category = X (Where X includes responses for category of "Yes" and "No" but does not include "N/A"
  
  Total with "Yes" for each category = Y
  
  Score Equation = Y/X

• Contractor Representative (First, Last, Title)

• Contractor Representative Signature

  Sign

• NAVFAC Representative (First, Last, Title)

• NAVFAC Auditor Signature

  Sign

• Comments: