Service Department

• Project Name &Number:

• Location
  Address

• Conducted on

  Date

• Technician

• Inspection reviewed with?

• Prepared by:

Soft Tissue Operations Mitigation Program

• Material handling plan in place. No lifting over 50 Lbs.

  Safe

  At Risk

  N/A

• Material Moving Equipment on site and in use (i.e. carts, dolleys,hoist, wire carts, fork lifts, etc.)

  Safe

  At Risk

  N/A

• Proper lifting procedures addressed on site specific plan and enacted on the field?

  Safe

  At Risk

  N/A

• Repetitive motion tasks addressed and plan in place to prevent injuries?

  Yes

  No

  N/A

• Team members trained on STOMP procedures

  Yes

  No

  N/A

• Supervisor set proper example to address STOMP issues – mechanical aids – Observations.

Personal Protective Equipment

• Hard hats, safety glasses in use by all personnel

  Safe

  At Risk

  N/A

• Gloves (sharp edges, using knives, handling materials)

  Safe

  At Risk

  N/A

• Proper foot gear and protective clothing. Traffic vest if necessary

  Safe

  At Risk

  N/A

• comments

Administration

• Safety manual available?

  Yes

  No

  N/A

• Emergency phone numbers posted?

  Yes

  No

  N/A

• Hazard communication program available?

  Yes

  No

  N/A

• Employees trained on GHS ?

  Safe

  At Risk

  N/A

• (SDS) Safety data Sheets manual current?

  Yes

  No

  N/A

• Proper labels on containers?

  Safe

  At Risk

  N/A

Medical/Emergency

• Emergency Action Plan available?

  Yes

  No

  N/A

• First-Aid Kit Available?

  Yes

  No

  N/A

• (BBP) Bloodborne Pathogens control plan available?

  Yes

  No

  N/A

• First-Aid/CPR trained personal onsite

  Yes

  No

  N/A

• Who is responsible for correcting this.

Person

• Select Safety Department Third party trainer Project Manager

  • Safety Department
  • Third party trainer
  • Project Manager

• What is the time frame to correct this?

  24 Hours

  Three days

  One week

  Other

  To be determined

• Incident investigation proecedure in place and forms available

  Yes

  No

  N/A

• Map to medical facility posted

  Yes

  No

  N/A

Electrical (General)

• Adequate lighting

  Safe

  At Risk

  N/A

• Signage present

  Safe

  At Risk

  N/A

• Electrical panels protected

  Safe

  At Risk

  N/A

• Electrical room protected

  Safe

  At Risk

  N/A

• Energized parts protected

  Safe

  At Risk

  N/A

• GFCI's used and functioning properly

  Safe

  At Risk

  N/A

• Safety plates on outlets and J boxes

  Safe

  At Risk

  N/A

• Approved three wire extension cords

  Safe

  At Risk

  N/A

• Ground prongs on cords

  Safe

  At Risk

  N/A

• Cords protected from traffic

  Safe

  At Risk

  N/A

Hot Electrical Work

• Hot Work Permit completed and signed

  Safe

  At Risk

  N/A

• JSA completed

  Yes

  No

  N/A

• All affected employees briefed

  Yes

  No

  N/A

• Back up person trained in emergency<br>procedure

  Safe

  At Risk

  N/A

• Proper level of PPE being used

  Safe

  At Risk

  N/A

• Electrical PPE inspected

  Safe

  At Risk

  N/A

• Insulated gloves tested and up to<br>date

  Safe

  At Risk

  N/A

• JSA steps and procedure being<br>observed

  Safe

  At Risk

  N/A

• Boundaries established and barriers set

  Safe

  At Risk

  N/A

• LOTO procedures being used

  Safe

  At Risk

  N/A

• Components de‐energized

  Safe

  At Risk

  N/A

• Energized parts protected

  Safe

  At Risk

  N/A

Ladders & Stairs

• Safe procedures being followed

  Yes

  No

  N/A

• Safe work distance kept from hazards

  Yes

  No

  N/A

• Ladders inspected

  Yes

  No

  N/A

• Employees not using top two rungs

  Yes

  No

  N/A

• Extension ladders extend 3 feet<br>above landing or secured at top

  Yes

  No

  N/A

• Step ladders in the open position

  Yes

  No

  N/A

• Rope for hoisting present with<br>extension ladders

  Yes

  No

  N/A

Fall Protection (29CFR 1926.500's)

• Fall protection plan (site specific)

  Yes

  No

  N/A

• Employees trained

  Yes

  No

  N/A

• Safety harness, lanyards, and<br>retractable inspected?

  Yes

  No

  N/A

• HLL and vertical life lines inspected<br>and used properly

  Yes

  No

  N/A

• Fall protection being used at 6 feet or higher

  Yes

  No

  N/A

• Harness being worn properly

  Yes

  No

  N/A

• Proper anchorage points used

  Yes

  No

  N/A

• Guardrails present

  Yes

  No

  N/A

Scissor & Aerial Lifts

• Operators following safety<br>procedures

  Yes

  No

  N/A

• Operators trained

  Safe

  At Risk

  N/A

• Equipment/workplace inspections<br>completed and documented

  Yes

  No

  N/A

• Harness and lanyard used in scissor<br>lift

  Yes

  No

  N/A

• Harness and lanyard used in aerial lift

  Yes

  No

  N/A

• Safe work distance kept from<br>elevation changes

  Yes

  No

  N/A

• Operating on a flat surface or rough<br>terrain

  Yes

  No

  N/A

• Gate or chain secured

  Yes

  No

  N/A

• Nothing used to increase height

  Yes

  No

  N/A

• Load ratings observed

  Yes

  No

  N/A

Motorized Equipment (Sky Jack, Backhoe etc.)

• What kind of equipment?

  Select Scissor Lifts Boom Lifts Back Hoe Mini Excavator Telescopic Handler Fork lift

  • Scissor Lifts
  • Boom Lifts
  • Back Hoe
  • Mini Excavator
  • Telescopic Handler
  • Fork lift

• Operator trained on that particular<br>equipment

  Yes

  No

  N/A

• Name the employees that require training and equipment.

• what equipment is he operating?

  Media

• How many years of experience does he have operating the equipment?

• When do we need to conduct training?

  With in two weeks

  3 weeks

  other

• Training documents available

  Yes

  No

  N/A

• Equipment inspections documented

  Yes

  No

  N/A

• Seat belt utilized

  Yes

  No

  N/A

• Back up alarm functioning

  Yes

  No

  N/A

• Brakes in working order

  Yes

  No

  N/A

• Horn functioning

  Yes

  No

  N/A

• Flagman used

  Yes

  No

  N/A

Hand & Power Tools

• Employees trained

  Yes

  No

  N/A

• Proper tool for the job

  Yes

  No

  N/A

• Information label on tool

  Yes

  No

  N/A

• Manufacturer instructions being<br>observed

  Yes

  No

  N/A

• Safe practices being observed

  Yes

  No

  N/A

• Tool in good condition

  Yes

  No

  N/A

• Cord in good condition

  Yes

  No

  N/A

• Double insulated tools used

  Yes

  No

  N/A

• Guards in place

  Yes

  No

  N/A

Excavations

• Competent person present

  Yes

  No

  N/A

• Utilities located and marked

  Yes

  No

  N/A

• Employees trained

  Yes

  No

  N/A

• Daily Inspections documented

  Yes

  No

  N/A

• Surface conditions acceptable

  Yes

  No

  N/A

• Fissures, cracks or shrinkage evident

  Safe

  At Risk

  N/A

• Walls sloped or shored

  Yes

  No

  N/A

• Proper access if is more than 4' deep

  Yes

  No

  N/A

• Access and exits within 25 feet

  Yes

  No

  N/A

• Perimeter protected/barricaded

  Yes

  No

  N/A

• Traffic exposure controlled

  Yes

  No

  N/A

• Top of box 18 inches above ground

  Yes

  No

  N/A

• Spoil 2 feet back from edge

  Yes

  No

  N/A

• Water entering excavation

  Safe

  At Risk

  N/A

Housekeeping

• Clear access to building or site

  Yes

  No

  N/A

• Walkways clear

  Yes

  No

  N/A

• Slip, trip, fall hazards protected and<br>clearly visible

  Yes

  No

  N/A

• Slip, trip, fall hazards eliminated

  Yes

  No

  N/A

• Work platforms clean

  Yes

  No

  N/A

• Materials properly stored

  Yes

  No

  N/A

• Tools and equipment put away after<br>use

  Yes

  No

  N/A

Site & Public Protection

• Public protection signage posted

  Yes

  No

  N/A

• Perimeter fence or barricades<br>installed

  Yes

  No

  N/A

• Traffic control plan in place

  Yes

  No

  N/A

• Adequate lighting provided

  Yes

  No

  N/A

• Technician Signature

  Sign

• Comments

• Safety Signature

  Sign

• Address behavioral issues positive and negative – Other general comments – PPE worn – Supervisor set proper example – accidents / near misses reported