Title Page

  • Conducted on

  • Prepared by

  • Location

Permits

  • CMRP Reviewed And Signed?

  • PTW Reviewed And Signed?

  • Roof Permit Reviewed And Signed?

  • Critical Lift Reviewed And Signed?

Work Area(s)

  • General Housekeeping

  • Walking/Working Surfaces

  • Unprotected Side/Holes

  • Impalement Hazards

  • Sanitary Facilities

  • Wate/Trash Receptacles

  • Material Storage Laydown

  • Barricades And Signs

Personal Protective Equipment

  • Hard Hats

  • Safety Glasses

  • Faceshield/Goggles

  • Respiratory Protection

  • Hearing Protection

  • High Visibility

  • Long Sleeves/FRC

  • Gloves

  • Foot Protection

Fall Protection

  • Trained/Competent

  • Worn Properly

  • Anchorage Points Used

  • Inspected/Color Coded

  • Stored Properly

  • 4FT Tie Off Policy Followed

Ladders

  • Proper Set Up

  • Inspected

  • Proper Type For Task

Tools

  • Good Condition

  • Inspected

  • Used Correctly

  • Tethered At Heights

Electrical

  • Extension Cords Inspected/Color Coded

  • Power Tools Inspected/Color Coded

  • Used Properly

  • Lock Out/Tag Out

Hot Work

  • Hot Work Permit Reviewed And Signed

  • Fire Watch Designated

  • Fire Extinguisher Present

  • Fire Extinguisher Inspected

  • Combustibles Removed/Protected

  • Barricade Present

  • Screening In Use

  • Fire Watch Present For 30 Mins After Completion

Rigging And Hoisting

  • Tag Legible

  • Rigging Capacity Reviewed

  • Hooks And Latches In Good Condition

  • Chain Falls/Come-A-Longs

  • Inspected/Color Coded

  • Tag Lines Used

  • Qualified Rigger

  • Whistles/Air Horns Used

Scaffold

  • Inspection Tag Present And Signed

  • Trained Personal

  • Handrails, Midrails, And Toe Boards

  • Deck/Plank Secured

  • Level Base

  • Access/Egress Good

  • Away From Powerlines

  • Barricaded

Crane Operation

  • Inspection Performed

  • Operator Manual Present

  • Set Up Properly

  • Swing Radius Barricaded

  • Flagger Present

  • Operator Certified

  • Lift Plan Present

Equipment

  • Inspection Performed

  • Certified Operation

  • Manual Present

  • Flagger Present

  • Set Up Properly

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.