Information
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Division
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Community
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Address
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Installation Contractor
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Conducted on
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Prepared by
1. Work Environment
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1.1. Lack of/or inadequate amenities? (Toilets, wash areas, lunch rooms, etc)
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1.2. Insufficient lighting?
2. Ladders
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2.1. Unsafe or damaged ladders?
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2.2. Unsafe positioning of ladders?
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2.3. Ladder extends 3' above landing?
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2.4. Ladder not properly secured?
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2.5. Ladder unsuitable for job?
3. Electrical Hazards
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3.1. Unsafe electrical leads? (Damaged, out of test date or untested)
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3.2. Contact with overhead electrical lines?
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3.3. Leads placed on ground or on metal structures?
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3.4. Electrical equipment near water?
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3.5. Electrical leads that may be damaged from contact with moving machinery parts?
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3.6. Lack of lock-out/tag-out (LOTO) procedures for electrical equipment?
4. Personal Protective Equipment (PPE)
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4.1. Lack of hard hats?
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4.2. Lack of eye protection?
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4.3. Lack of hard sole shoes?
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4.4. Lack of Sun protection?
5. Fall Protection
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5.1. Unsafe or damaged harness or equipment?
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5.2. Unsafe anchor points?
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5.3. Unlabeled or does not meet AS?
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5.4. Current employer specific fall protection plan in place?
6. Emergency Response
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6.1. Lack of training and rehearsal of emergency plans?
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6.2. Insufficient access to formally trained First Aiders for all shifts?
7. Equipment
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7.1. Properly trained to operate equipment?<br>
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7.2. Proper loading and unloading procedures being followed?
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7.3. Operator in cab while load is suspended?
8. Housekeeping
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8.1. Clean site on and around work space area?
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8.2. Trash properly placed and removed from work area?
9. Tools
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9.1. Guard in place on tools?
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9.2. Tools in proper working condition?
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9.3. No tools damaged in use?
10. Scaffolds
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10.1. Filly planked?
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10.2. Scaffold grade lumber?
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10.3. Guard rails 6' (7 1/2" CA)?
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10.4. Base plate/mud Sills?
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10.5. Cross bracing?
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10.6. Scaffold level with screw jacks?
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10.7. Damaged parts?
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10.8. Access ladder?
Corrective Actions
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Enter any corrective actions that will be undertaken
Sign Off
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On site representative
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Auditor's signature
