Title Page

  • Date/Time:

  • Contractor:

  • Crew Size:

  • Location:
  • Observer:

  • Overall Comments:

PPE

  • Face Protection

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Fall Protection

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Foot Protection

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Gloves (As Required)

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Hard Hats

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Hearing Protection

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • High Visibility Clothing

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • PowerSafe Stickers

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Protective Clothing

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Respirators/SCBA

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Safety Glasses

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Other

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

ERGONOMICS AND POSITIONING

  • 3-Point Contact

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Clear of Excavating/Operating Equipment

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Clear of Suspended Loads

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Load Carried Close to Body

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Move, Don't Reach

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • SIF: Pinch Point

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Proper Lifting Technique

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Push, Don't Pull

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Squat, Don't Bend

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Standing Under Workers Aloft Unnecessarily

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Turn, Don't Twist

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Working Above Floor of Basket

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Other

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

HOUSEKEEPING

  • Fire Extinguishers

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • First Aid Kit

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Flammable Liquid Storage

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Opening Protection

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Site Access

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Vehicle/Equipment

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Working Areas Clear of Debris/Material

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Other

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

VEHICLE/EQUIPMENT USE

  • Backing Equipment/Spotter

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Emergency Brake

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Employees Clear of Operating Equipment

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Load Secure

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Outrigger Placement

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Rigging

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Trailer Hookup

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Using Seatbelts Where Provided

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Wheels Chocked

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Work Zone Traffic Protection

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Vehicle/Equipment Use Outside of MAD

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Other

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

POLICY AND PROCEDURES

  • Aerial Lifts

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Compressed Gas Storage

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • SIF: Confined Space Entry

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Excavation Opening Protection

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Grounding of Trucks/Equipment

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Jewelry

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Job Briefings

  • Job Briefing

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Ongoing Crew Member Communication

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Personal Voltage Device

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Pre-Use Inspection of Tools/Equipment

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Proper Apparel (FR)

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Proper Use of Handline

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Proper Use of Ladders

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Proper/Defective Tool

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Scaffolding

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Trenches Sloped/Shored

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

  • Other

  • Description of What Was Observed:

  • Add media

  • Action Taken:<br>

  • Feedback:

Review

  • Contractor Supervisor:

  • Ameren Supervisor:

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.