Title Page

  • Project Name/ Number

  • Project Location
  • Project Manager

  • Project Engineer

  • Supervisor/ Foreman

  • Number of Employees

  • Conducted on

  • Prepared by

General Assessment

Frontline Safety

  • Safety Committee that will meet once per week

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Weekly "All Hands Toolbox" meeting

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Weekly Frontline Safety Meeting (telephone call)

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Established Safety Observation process

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Weekly Walk-Downs by Craft program

  • Have action items from previous assessment been completed?

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

Hazard Communication

  • SDS andChemical lists maintained on site

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Has SDS and Chemical list been updated for new products?

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Employees trained on HAZCOM and specific chemicals in use

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Proper identification labels on cans/ portable containers

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

Housekeeping

  • Proper rebar caps used to eliminate impalement

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Work areas clean of excess construction debris

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Nails pulled from wood before handling

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Proper storage of materials, supplies, and equipment

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Proper walkway maintained (ice, oil, chords, airlines, etc.)

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Tools and equipment stored properly

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

Job Site Requirements

  • Bloodborne pathogens kits available

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Emergency Action Plan posted

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • First aid kits/ Eye wash/ Burn Stations maintained

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • OSHA (5 in 1) minimum wage, discrimination, state posters

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Supervision has current First Aid and Adult CPR training

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

Public/ Other Worker Protection

  • Pedestrian signs; barriers; fences; gates; flagging

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Dust curtains are taped W/ doors and access areas

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Noise controls are in place (monitoring; barriers; distance)

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Life rings, 90 feet of rope and air horn near water hazards

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Open holes covered or barricaded with fencing or guardrails

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Overhead protection (falling; flying debris; tool and equipment)

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Pedestrian walkways protected from trip and slip hazards

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Property's glass; tile; flooring and vehicles protected

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Public protected from construction exposures

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Comments:

  • Public warning and hazard signs clearly posted

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Traffic controls maintained (signs, direction, barricades)

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

Safety Culture

  • Buddy System (Mentor) being utilized for new employees

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Commitment to Safety Board is signed and displayed

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Follow-up on action items from weekly safety team meeting

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Employees have completed new hire training

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Project pre-plan onsite and reviewed with employees

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Pre Task Planning completed for new tasks

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Project team dedicated time to safety meetings/ action items

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

Sanitation

  • Drinking water containers cleaned and sanitized daily

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Drinking water with disposable cups and trash receptacle

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Proper means of disposal (dumpsters, trash cans)

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Proper number of toilets and wash-up facility provided

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

Company Vehicle Requirement

  • Load is stable/ secured properly (not overload)

  • Comments:

  • Date Due:

  • Action Required:

  • Person Assigned:

  • Comments:

  • Required safety equipment on vehicle (fire extinguisher, first aid kit, etc.)

  • Comments:

  • Date Due:

  • Action Required:

  • Person Assigned:

  • Comments:

  • Tow hitches and ball hitch connections maintained

  • Comments:

  • Date Due:

  • Action Required:

  • Person Assigned:

  • Comments:

  • Towing equipment properly connected (safety chains, brakes)

  • Comments:

  • Date Due:

  • Action Required:

  • Person Assigned:

  • Comments:

QA/QC Assessment

Frontline Quality

  • Is there a written Project Quality Plan, completed and signed off? <br>(Review plan, check for updates and completeness)

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Has a frontline Quality team been established with regular meetings? <br>(Review recent agendas, action items, SORs)

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Procedures developed for tasks identified in risk analysis? <br>(Project Risk Analysis, current activities evaluated?)

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Has crew received training on identified tasks with training verified? <br>(Review records and interview crew)

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Mock up plan establish?

  • List mock ups recently completed and upcoming (Review Mock Up report form)

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Are hold points established?

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • QC testing and inspections ongoing and documented? (Review QC testing and inspection documents)

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Material receiving inspection plan established and implemented?

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Subcontractor Quality Plan established and implemented? <br>(Review Sub's plan)

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • NCR and CAs reviewed and status noted?

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

Industrial (Nuclear, Chemical, Power, Pipe)

Aerial Lifts: (Articulated, Scissor)

  • Area around swing radius is properly barricaded

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Workplace hazards identified before use

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Employees maintaining fall protection attachment(s)

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Railings not used for work access

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Stable, level drive area

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Equipment not used as a crane to lift materials

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

Compressed Air and Gas Cylinder Safety

  • Air compressors properly maintained and used

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • All connections are double pinned with whip check installed

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Compressed air receiver tanks equipped with blow off valve

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Compressed gas cylinders stored and secured vertically

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Threaded connection for airlines (2" or greater)

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Cylinders have caps installed when not in use

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Flash back arresters installed at cylinder regulator

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Oxygen and fuel gases stored 20' apart or separated by fire proof wall

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • OSHA valves installed on 3/4" or greater lines (pneumatic tools)

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

Confined Space Entry

  • Natural/ mechanical ventilation in place

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Atmospheric gas testing completed (pre-entry/ continuous)

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Gas detection equipment is calibrated and used properly

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Required permits current and available at entry point

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Attendant available at entry point (comm. equip. and permits)

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Has emergency services been identified for confined space rescue

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Emergency evacuation procedure in place

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

Cranes/ Lifting Equipment

  • Equipment swing radius barricaded

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Lift plans are complete and reviewed with crew before work starts

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Overhead electrical hazards have been identified

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Qualified operators and signal person in use

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Rated load capacities posted on equipment

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

Electrical Safety

  • Adequate lighting for work areas (guarded lenses)

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Assured grounding inspection and taping done correctly

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Elec. tools unplugged if repairing or changing bits; blade; etc.

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Electric panel boxes have proper covers

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • GFCI provided for cords and equipment

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Extension cords are 12 gauge/ 3 wire minimum

  • Comments:

  • Due Date:

  • Action Completed:

  • Person Assigned:

  • Comments:

Elevated Work Access

  • Elevated work access properly planned

  • Comments:

  • Due Date:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Fall protection measures in place for all work zones

  • Comments:

  • Due Date:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Primary and secondary egress routes available for all work zones

  • Comments:

  • Due Date:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Emergency rescue plan in place for all work zones

  • Comments:

  • Due Date:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Employees are trained on their role in an emergency

  • Comments:

  • Due Date:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Operational non-powered descent device on site

  • Comments:

  • Due Date:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Adequate level of communication between ground/ upper work elevations

  • Comments:

  • Due Date:

  • Action Completed:

  • Person Assigned:

  • Comments:

Fall Protection

  • Anchor point of 5000 lbs. per employee or engineered anchorage

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Floor and walkway openings protected

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Fall equipment inspections are completed

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Employees are maintaining 100% fall protection program

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Floor openings covered, clearly marked and secured

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Vertical and horizontal life lines properly used and inspected

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Handrails are properly constructed- top middle and toe board

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

Fire Safety

  • Equipment turned off while fueling

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Exit, stairs, and walkways are clear (36" minimum walkway)

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Fire extinguishers are of adequate size and placement (10 lb. min.)

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Flammable storage area is 20' from buildings

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Flammables and combustibles stored separately

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Fuels cans no larger than 5 gallon with flash arrestor/ spring locks

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Fuel storage area: signs/ containment/ >20 lbs. extinguisher

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • No smoking signs posted (smoking areas clearly marked)

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Oily rags stored in proper container W/ self closing lid

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Welding/ burning: No combustibles/ fire extinguisher present

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Hot work permit in use (when required)

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

Hand Tools and Power Equipment

  • Power equipment clean and free of damage

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Grinders used with guards and handles at all times

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Hand tools clean and free of damage

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Hand tools secured from falling (working at heights)

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Power tools are double insulated with proper grounding connection

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Running equipment not left unattended

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Sand pots: properly used, clean, and free of damage

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Pressure washers: properly used, clean, and free of damage

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Saws: properly used, clean and free of damage

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

Lock-Out/ Tag-Out Program

  • Energy isolation devices identified and secured

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Group lock-out box in use with supervisor's lock in place

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Individual employee locks are labeled and in use

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Lock-out point has a "Do Not Operate" tag attached

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Written program in place (company or client provided)

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Tags are completely filled out

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

Motorized Equip. (Forklift; Con. Buggie; Skid Steer)

  • Employee qualified to operate equipment

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Equipment inspection completed before use (daily)

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Lift is used within rated capacity

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Propane is shut off when not in use

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Attachments inspected and manufactured for intended use

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

Mixing/ Grouting/ Gunite Equipment

  • Dust containments are established in public areas

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Employees are wearing correct PPE for identified tasks

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Equipment is shut down for cleaning (LO/TO where needed)

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Machines are maintained and greased daily

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Material placement does not create tripping hazards

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Team lifting practices for bags (50 lb. or greater)

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Safety devices are in place and operational

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

Personal Hoist and Man Cages

  • Installed correctly (per drawings or manufacturer's recommendation)

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Inspected on a frequent basis

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Defective items are removed from service and/or corrected

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Qualified employee is operating hoist machine

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Drop test procedures in place

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Hoist variance on site

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Hoist machine engine vented to fresh air (CO Monitoring)

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Overhead lifting zone barricaded and properly signed

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Proper signage posted outside lifting zones

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Lifting cables are properly guarded

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Sheaves, pulleys, blocks, etc. properly guarded and installed

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Access landings have proper clearance and fall protection guards

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Man basket usage:

  • 1.) Load rating marked on basket

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • 2.) Properly inspected (daily, weekly, monthly, annual)

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • 3.) Operator at controls while load is suspended

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • 4.) Three full wraps on winding drum

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

Personal Protective Equipment

  • Chemical Protective Clothing (Tyvek, Rain Suits, Etc.)

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Company Issued Blue Hard Hats

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Eye protection (Z-87.1 and rated for Task)

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Flotation devices (PFD- Personal Flotation Device)

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Hand Protection/ Hand Injury Awareness

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Hearing Protection (Noise levels greater than 85 dB)

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Work Boots: Leather/ Die Electric/ Steel Toe/ Metatarsal/ Other

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

  • Reflective Clothing/ Vests- As determined by project

  • Comments:

  • Date Due:

  • Action Completed:

  • Comments:

  • Person Assigned:

Respiratory Protection

  • All airborne (respiratory hazards) have been identified

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Employees are clean shaven when using respiratory protection

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Fitted respirator users trained, provided physicals, and fit tested

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Proper respiratory protection has been selected for hazards

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Respiratory cleaning/ disinfection supplies provided

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Respirators are stored in protective bags when not in use

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Respirators are being worn properly

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

Scaffold And Ladder Access

  • Ladder tip extends 36" beyond landing area

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Ladders are inspected daily and in good working condition

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Ladders are installed with 4:1 standard ratio

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Ladders are secured before employee work begins

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Ladders are non-conductive and have non-skid feet

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • 3 points of contact maintained on ladder

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Scaffold has adequate cross bracing with positive locking devices

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Scaffold modifications made by competent person only

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Scaffolding system is properly tagged and inspected

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Work decks are secured to scaffolding and free of debris

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Work decks are complete without spacing/ openings

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

Trenching/ Excavation Safety

  • Competent person evaluating: shoring, benching, sloping

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Excavation access are properly guarded at ground level

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Excavation is being monitored for gases (greater than 4' deep)

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Ladder access provided (min. 25' travel distance) for entry and exits

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

  • Shoring devices are engineered and in good working condition

  • Comments:

  • Date Due:

  • Action Completed:

  • Person Assigned:

  • Comments:

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.