Title Page
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Conducted on
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Prepared by
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Location
Permits
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CMRP Reviewed And Signed?
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PTW Reviewed And Signed?
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Roof Permit Reviewed And Signed?
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Critical Lift Reviewed And Signed?
Work Area(s)
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General Housekeeping
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Walking/Working Surfaces
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Unprotected Side/Holes
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Impalement Hazards
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Sanitary Facilities
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Wate/Trash Receptacles
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Material Storage Laydown
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Barricades And Signs
Personal Protective Equipment
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Hard Hats
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Safety Glasses
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Faceshield/Goggles
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Respiratory Protection
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Hearing Protection
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High Visibility
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Long Sleeves/FRC
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Gloves
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Foot Protection
Fall Protection
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Trained/Competent
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Worn Properly
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Anchorage Points Used
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Inspected/Color Coded
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Stored Properly
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4FT Tie Off Policy Followed
Ladders
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Proper Set Up
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Inspected
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Proper Type For Task
Tools
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Good Condition
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Inspected
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Used Correctly
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Tethered At Heights
Electrical
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Extension Cords Inspected/Color Coded
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Power Tools Inspected/Color Coded
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Used Properly
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Lock Out/Tag Out
Hot Work
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Hot Work Permit Reviewed And Signed
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Fire Watch Designated
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Fire Extinguisher Present
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Fire Extinguisher Inspected
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Combustibles Removed/Protected
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Barricade Present
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Screening In Use
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Fire Watch Present For 30 Mins After Completion
Rigging And Hoisting
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Tag Legible
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Rigging Capacity Reviewed
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Hooks And Latches In Good Condition
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Chain Falls/Come-A-Longs
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Inspected/Color Coded
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Tag Lines Used
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Qualified Rigger
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Whistles/Air Horns Used
Scaffold
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Inspection Tag Present And Signed
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Trained Personal
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Handrails, Midrails, And Toe Boards
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Deck/Plank Secured
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Level Base
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Access/Egress Good
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Away From Powerlines
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Barricaded
Crane Operation
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Inspection Performed
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Operator Manual Present
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Set Up Properly
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Swing Radius Barricaded
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Flagger Present
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Operator Certified
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Lift Plan Present
Equipment
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Inspection Performed
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Certified Operation
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Manual Present
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Flagger Present
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Set Up Properly
