Title Page
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Conducted on
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Prepared by
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Location
Inspection Information
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Project Name:
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Observer Name:
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Date:
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Location:
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Business Unit Director:
Conditions
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Visibility of EHS: Signs, posters, safety calendar, site orientation
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Emergency Plan: Evacuation routes and assembly points posted, medical available, fire protection, alarms
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Housekeeping: Clean, orderly, materials properly stored, trash properly disposed
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Excavations: Properly shored/ sloped, safe access, protected from traffic, spoils piles
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Scaffold/Stairs/Ladders: Safe access, working safely, inspected, proper use, secured
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Chemicals and Equipment: Chemicals stored properly, labeled, no visible spills, spill containment in place
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Lifting and Rigging Practices: Slings/chains no damage, use of certified lifting devices, tag lines, crane inspections
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Safe Walkways and Access: Clear designated walkways, tripping hazards, cables run safely
Behaviors
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Safe Equipment and Tool Use: Right for the job, inspected, used correctly
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Personal Protective Equipment: Proper use, worn correctly, required for the hazard
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Permit to Work Use: LOTO, electrical energized work, welding permits used and followed
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Exposure to Falls: Unsafe position, exposure to a fall, safe use aerial/scissor lifts
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Contacting Electrical Hazard: Electrical safe work practices, use of PPE (Arc Flash)
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Awkward Positions: Improper lifting, work positioning, reaching working over head
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Caught in or Between Objects: Working in confined spaces, excavations, engulfment
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Striking Against or Being Struck By: Crane swing, mobile equipment, lifting materials
General
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Additional Comments
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Additional Media
Sign Off
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Sign off by Observer
