Summit Safety Assessment

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Previous Assessment

• Has the previous Assessment been reviewed?

  Yes

  No

  N/A

• Were all issues resolved?

  Yes

  No

  N/A

• What issues were left unresolved?

Job Safety Analysis

• JSA Completed

  Yes

  No

  N/A

• Signed by everyone on job site

  Yes

  No

  N/A

• All hazards identified

  Yes

  No

  N/A

Personal Protective Equipment

• Hard Hats used by all personnel

  Yes

  No

  N/A

• Eye Protection used by all personnel

  Yes

  No

  N/A

• Hearing Protection

  Yes

  No

  N/A

• Proper foot protection

  Yes

  No

  N/A

• Fire Resistant Clothing

  Yes

  No

  N/A

• Fall Protection

  Yes

  No

  N/A

• Respirators/Face Masks in good condition and used as required (Medical Evaluation and Fit Test)

  Yes

  No

  N/A

• All PPE in good condition and clean

  Yes

  No

  N/A

Tools and Equipment

• Tools and Equipment in good condition

  Yes

  No

  N/A

• Electrical equipment connected properly, grounded and in good repair; GFCI working

  Yes

  No

  N/A

• Rigging/Lift Equipment in good condition and repaired

  Yes

  No

  N/A

• Ladders inspected, tied back and extended 3 ft beyond landing

  Yes

  No

  N/A

Heavy Equipment

• Daily Inspection completed

  Yes

  No

  N/A

• Operator qualified to operate equipment

  Yes

  No

  N/A

• Seat Belt/Fall Protection worn during operation

  Yes

  No

  N/A

• Back up alarm operable / Guide used

  Yes

  No

  N/A

• Fire Extinguisher mounted, inspected, and in good condition

  Yes

  No

  N/A

• Equipment on site (Unit #, Make, Model)

Vehicles and Trailers

• Daily inspection completed

  Yes

  No

  N/A

• Vehicles safe / good condition; DOT compliant

  Yes

  No

  N/A

• Trailers safe / good condition; DOT compliant

  Yes

  No

  N/A

• Vehicles clean and organized

  Yes

  No

  N/A

• Vehicles / Trailers damaged

  Yes

  No

  N/A

• Vehicles / Trailers on site (Unit #, Make, Model)

Hazardous Materials

• List of hazardous chemicals available

  Yes

  No

  N/A

• Material Safety Data Sheets available

  Yes

  No

  N/A

• Proper containers used with correct label

  Yes

  No

  N/A

General

• Safe access to work area

  Yes

  No

  N/A

• Good housekeeping and material storage

  Yes

  No

  N/A

• Excavation / Trenches properly protected

  Yes

  No

  N/A

• Warning signs in place and readable

  Yes

  No

  N/A

• Eye Wash available

  Yes

  No

  N/A

• First Aid kit available and stocked

  Yes

  No

  N/A

• At least one person trained in 1st Aid / CPR on site

  Yes

  No

  N/A

Comments / Observations

• What follow up action is required?

• Comments, Concerns, Reccomendations

Reviewed by:

• Job Site Supervisor

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• Safety Representative

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