Information

  • Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by:

  • Location
  • Personnel

    JSA
  • JSA Complete?

  • Does Headcount Match JSA Signatures?

  • PIC on Location:

  • Additional Documentation (EAP, SSSP, Inspection Checklists, & Permits):

  • Emergency Action Plan (1910.38)

  • Site Specific Safety Plan (1910.38)

  • Equipment Inspection Checklist

  • Crane Inspection Checklist

  • Customer Permits

  • Confined Space (1926.1201)
  • Confined Space

  • Has the atmosphere been tested and is being monitored? <br>Oxygen (19.5% - 23.5%)<br>Lower explosive limit (LEL <1%)<br>Hydrogen Sulfide (H2S ppm <10%)<br>Carbon Monoxide (CO ppm, <1%)

  • Electrical Safety (1926.416)
  • Electrical Safety

  • Equipment
  • Equipment

  • Excavation Safety (1926.651)
  • Excavation Safety

  • Excavation Permits / Checklists complete?

  • Fall Protection (1910.21)
  • Fall Protection

  • Fire Protection & Prevention (1926.150)
  • Fire Protection & Prevention

  • First Aid Kit (1910.266)
  • First Aid Kit

  • Hand and Power Tools (1910.242)
  • Hand and power tools to be inspected in this audit?

  • Hot Work (1910.252)
  • Hot Work

  • Has the atmosphere been tested and is being monitored? <br>Oxygen (19.5% - 23.5%)<br>Lower explosive limit (LEL <1%)<br>Hydrogen Sulfide (H2S ppm <10%)<br>Carbon Monoxide (CO ppm, <1%)

  • Fire Watch

  • Housekeeping (1926.25)
  • Housekeeping

  • Ladder Safety (1910.23)
  • Ladder Safety / Inspection

  • Lock-Out / Tag-Out (1926.417(a) & 1926.(b))
  • Lock-Out / Tag-Out

  • Lock-Out / Tag-Out Documentation Completed?

  • Material Handling (1926 Subpart H)
  • Material Handling

  • Overhead Power Lines (1926.1410)
  • Overhead Power Lines

  • PPE (1926.95)
  • Required PPE

  • Restrooms & Potable Water (1926.51)
  • Restrooms & Potable Water

  • Signs/Barricades (1926.1424)
  • Signs/Barricades

  • Stored Materials (1926.25)
  • Stored Materials

  • Traffic Control (1926 Subpart G)
  • Traffic Control

  • Welding Activities (1926.351)
  • Welding Activities

  • Comments:

  • Photos

Signatures

  • Safety Signature:

  • Supervisor Signature:

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