South Austin Medical Center

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Contractor acknowledges proper insurance, certification, licensure

  Yes

  No

  N/A

• Select yes no N/A

  • yes
  • no
  • N/A

• Add media

  Media

• Adequate barriers in place

  Yes

  No

  N/A

• Select yes no N/A

  • yes
  • no
  • N/A

• Add media

  Media

• Shoring in place if deeper than 4 feet

  Yes

  No

  N/A

• Select yes no N/A

  • yes
  • no
  • N/A

• Add media

  Media

• Utilities located prior to excavation

  Yes

  No

  N/A

• Select yes no N/A

  • yes
  • no
  • N/A

• Add media

  Media

• Proper powered equipment being used (backhoe, trencher, bobcat, etc.)

  Yes

  No

  N/A

• Select yes no N/A

  • yes
  • no
  • N/A

• Add media

  Media

• Equipment operator properly trained/ licensed for use

  Yes

  No

  N/A

• Select yes no N/A

  • yes
  • no
  • N/A

• Add media

  Media

• Underground Risk Assessment performed

  Yes

  No

  N/A

• Select yes no N/A

  • yes
  • no
  • N/A

• Add media

  Media

• Proper ventilation in place for trenches deeper than 4 feet

  Yes

  No

  N/A

• Select yes no N/A

  • yes
  • no
  • N/A

• Add media

  Media

• Interim Life Safety Measures (ILSM) in place, if needed

  Yes

  No

  N/A

• Select yes no N/A

  • yes
  • no
  • N/A

• Add media

  Media

• Contractors trained regarding ILSM

  Yes

  No

  N/A

• Select yes no N/A

  • yes
  • no
  • N/A

• Add media

  Media

• Temporary Fire Prevention in place

  Yes

  No

  N/A

• Select yes no N/A

  • yes
  • no
  • N/A

• Add media

  Media

• Contractors aware of egress routes

  Yes

  No

  N/A

• Select yes no N/A

  • yes
  • no
  • N/A

• Add media

  Media

• Traffic control

  Yes

  No

  N/A

• Select yes no N/A

  • yes
  • no
  • N/A

• Add media

  Media

• All exits clear

  Yes

  No

  N/A

• Select yes no N/A

  • yes
  • no
  • N/A

• Add media

  Media

• Free access to Emergency Services

  Yes

  No

  N/A

• Select yes no N/A

  • yes
  • no
  • N/A

• Add media

  Media

• Alternate routes for public and emergency use

  Yes

  No

  N/A

• Select yes no N/A

  • yes
  • no
  • N/A

• Add media

  Media

• Smoking is strictly prohibited

  Yes

  No

  N/A

• Select yes no N/A

  • yes
  • no
  • N/A

• Add media

  Media

• Construction site clean and orderly

  Yes

  No

  N/A

• Select yes no N/A

  • yes
  • no
  • N/A

• Add media

  Media

• Contractors are informed if adjacent areas affected

  Yes

  No

  N/A

• Select yes no N/A

  • yes
  • no
  • N/A

• Add media

  Media

• Construction site access restricted

  Yes

  No

  N/A

• Select yes no N/A

  • yes
  • no
  • N/A

• Add media

  Media

• Will there be any Noise and Vibration Risks? (Noise and Vibration Risk Assessment" form required if answered "Yes")

  Yes

  No

  N/A

• Select yes no N/A

  • yes
  • no
  • N/A

• Add media

  Media

• Select date

  Date

• Add signature

  Sign

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