Information

  • Document No.

  • Site Name

  • Region/Market

  • Conducted on

  • Prepared by

  • Location Address
  • Project Number

Project and Site Details

  • Client

  • Property Owner

  • Number of Jacobs personnel on site:

  • Crew Foreman/Leader

  • Scope of Work

  • Are there any subcontractors on site?

  • Subcontractors name

  • Subcontractors Scope of Work

  • How many subcontractor personnel on site?

  • Jacobs Construction Manager

  • Jacobs Project Manager

  • Will elevated work occur on this project site?

  • Monopole

  • Self-Supporting Tower

  • Guyed Tower

  • Water Tank

  • Rooftop

  • Crane Supported Work Platform

  • Spider Basket

  • Aerial Lift of Scissor Lift

  • Bucket/Boom truck

  • Other

  • Describe:

  • Insert photo of structure where elevated work is occurring or will occur.

Jobsite Documentation

  • Is a Daily Safe Plan of Action completed and on site?

  • Rate the quality and completeness of the SPA, with a 0 being poor quality and 10 being high quality.

  • Will elevated work take place on this site?

  • Is the Elevated Work Permit completed and on site?

  • Rate the quality and completeness of the permit, with 0 being poor quality and 10 being high quality.

  • Is a Safety Binder on site with all required documentation?

  • Are originals or copies of the Competent Climber certifications of all personnel who will work at elevation available on site?

  • Is there a completed Emergency Action Plan for the site?

  • Is there a Competent Persons list on site?

  • Is the Competent Persons list current and site-appropriate?

  • Are there at least 2 persons on site currently certified in First Aid/CPR?

  • Are overhead utilities and other electrical hazards addressed in the SPA?

  • Are overhead or underground utilities marked to prevent disturbance?

  • Are MSDS's available on site for all chemicals, compounds, and hazardous substances?

  • Is an Incident Reporting Manual on site with all reporting forms?

  • Overall compliance with field site documentation requirements:

  • Describe deficiencies:

  • Deficiency
  • Deficiency

  • Add media

  • Document remedial actions taken:

Jobsite Contitions

  • Is the worksite clean of trash and debris?

  • Are materials stored properly and orderly?

  • Are measures taken to prevent access to the site by unauthorized personnel?

  • Are work areas barricaded or fenced?

  • Is there signage posted at the entrance to the site establishing PPE and access instructions for visitors?

  • Is drinking water available?

  • Are chemical, flammable and combustilble liquids stored properly? (No plastic storage cans)

  • Is at least one 10lb ABC fire extinguisher availalbe, fully charged and with current inspection?

  • Are plant, animal and biological hazards addressed and documented on the SPA?

  • Are weather (heat, cold, precipitation, lightening, ice/snow) addressed and documented on the SPA?

  • Overall compliance with jobsite conditions management

  • Describe Deficiencies:

  • Deficiency
  • Deficiency:

  • Insert Photo of Deficiency, if applicable.

  • Describe remedial actions taken:

PPE

  • Are employees wearing hard hats 100% of the time?

  • Document remedial actions taken:

  • Are employees weating ANSI Z87 safety glasses 100% of the time?

  • Document remedial actions taken:

  • Are employees wearing appropriate gloves for the tasks performed 100% of the time?

  • Document remedial actions taken:

  • Are employees wearing hi-viz clothing?

  • Document remedial actions taken:

  • Are employees wearing appropriate hard-toe footwear?

  • Document remedial actions taken:

  • Are employees dressed in appropriate work clothing?

  • Document remedial actions taken:

  • Is hearing protection needed for potential noise exposures over 85dB?

  • Tap to enter information
  • Are ear plugs or ear muffs available for employees on site?

  • Are employees with exposures to noise over 85dB wearing appropriate hearing protection?

  • Document remedial actions:

  • Other PPE in use on this site:

  • Other PPE needed on this site:

  • Overall compliance with PPE requirements:

Fall Protection

  • Do employees who are exposed to falls have proper training?

  • Is fall protection equipment being inspected daily and documented on the Elevated Work Permit?

  • Are all inspection tags on fall protection equipment present and legible?

  • If the work performed requires fall protection, is it being used 100% of the time?

  • Persons in violation of 100% fall protection shall be removed from site. Further disciplinary procedures may apply.

  • Document remedial actions taken.

  • Is work being performed on a rooftop or other elevated flat surface?

  • Are the following conditions met?

  • Tap to enter information
  • Describe method of fall protection

  • Is a documented, site-specific rescue plan in place?

  • Is there a rescue kit on site with dedicated rope and rescue equipment?

  • Overall compliance with Fall Protection requirements:

  • Deficiencies noted:

  • Deficiency
  • Describe deficiency:

  • Add photo if applicable

  • Document remedial actions

RF

  • Have RF hazards been considered and the safe plan documented on the Safe Plan of Acton?

  • Is there a procedure in place to reduce RF exposure, if applicable?

  • Does client of site owner require specific RF protection plans?

  • Are our operations on site in compliance with client and owner requirements?

  • Document remedial actions:

Capstans and Hoists

  • Is hoist operator qualified (Certified through training or Qualified through experience)?

  • Document remedial actions taken:

  • Are daily inspections being completed with documentation on site?

  • Is there a documented lift plan for the site?

  • Is there an operators manual for the unit(s) on site?

  • Are the load charts readily available for hoist operators?

  • Are all hoists secured and properly anchored for the load intended?

  • Is the end connection properly secured?

  • Are hoist controls clearly identified?

  • Are hoist controls easily accessbile to the operator?

  • Are all exposed parts properly guarded?

  • Is the hour meter operational and functioning properly?

  • Detail Hoist Unit Condition and Hours

  • Hoist
  • Hoist Unit

  • Condition:

  • Hours:

  • Overall compliance with hoist safety requirements:

  • Tap to enter information
  • Deficiencies noted:

  • Deficiency
  • Document remedial actions required:

Cranes

  • Is there crane work associated with this project?

  • Have crane picks been planned and the plans documented?

  • Has the crane subcontractor submitted proof of annual inspection of the crane?

  • Has the crane subcontractor submitted evidence of the crane operator's NCCCO certification?

  • Does the crane signal person have current certification?

  • Are the pick plans documented and approved?

  • Has the Rigger been trained in appropriate rigging practices?

  • Has all rigging equipment been inspected and the inspection documented?

  • Is the swing radius of the crane barricaded?

  • Are the outriggers extended and blocked?

  • Will there be personnel hoisted by the crane?

  • Tap to enter information
  • Has a crane-suspended personnel platform pre-lift checklist been completed and made available on site?

  • Has a pre-lift safety meeting been held and documented?

  • Overall compliance with crane requirements?

  • Tap to enter information
  • Deficiencies noted:

  • Deficiency
  • Describe deficiency

  • Add photo, if applicable

  • Document remedial actions taken:

Elevated Work Platforms & Aerial Devices

  • Are Elevated Work Platforms or other Aerial Work Devices being used or to be used on this site?

  • Tap to enter information
  • Does the daily Safe Plan of Action adequately address the type of elevated work platform and hazards associated with the device?

  • Were additional checklists or planning documents used to plan this work?

  • Are all personnel performing elevated work using 100% fall protection?

  • Are the equipment operators Qualified to operate the device?

  • Overall compliance with elevated work platform and aerial device requirements:

  • Deficiencies noted:

  • Deficiency
  • Describe deficiency

  • Add photo, if applicable

  • Describe remedial actions taken:

Rigging and Blocks

  • Will there be rigging of equipment, materials or tools to be hoisted on this site?

  • Are proper rigging practices being utilized?

  • Are Riggers properly Qualified for the rigging work performed?

  • Tap to enter information
  • Qualification is based upon:

  • Is rigging equipment in good condition?

  • Is rigging equipment able to be individually identified with inventory control markings or tags?

  • Are capacity tags legible?

  • Is rigging equipment being inspected daily and the inspection documented on the daily Safe Plan of Action or Elevated Work Permit?

  • Has the equipment been thoroughly inspected on a quarterly basis and the inspection documented?

  • Are ropes in good condition?

  • Are tag lines in good condition?

  • Are tag lines used on all lifts?

  • Overall compliance with rigging and blocking requirements:

  • Deficiencies noted:

  • Deficiency
  • Describe deficiency

  • Add photo, if applicable

  • Describe remedial actions taken:

Gin Poles

  • Are gin poles in use or to be used on this site?

  • Equipment ID of gin pole

  • Has the gin pole been inspected prior to use, and is the inspection available on site?

  • Does the gin pole have a rated hoisting capacity displayed on the equipment?

  • Has the daily safe plan of action addressed the use and hazards associated with gin poles?

  • Have other checklists been used to plan the work?

  • Is gin pole being used in accordance with all requirements detailed in the Jacobs Policy on Gin Pole Use in Construction and Demolition of Telecommunications Towers?

  • Document remedial actions taken:

  • Is the gin pole rigging in good condition?

  • Does the sheave in the rooster head match the wire rope?

  • Are all intended loads less than 85% of the capacity of the gin pole?

  • Document remedial actions taken:

  • Overall compliance with gin pole requirements

  • Tap to enter information
  • Deficiencies noted:

  • Deficiency
  • Describe deficiency

  • Add photo, if applicable

  • Document remedial actions:

Ladders

  • Are all ladders on site rated at least A1?

  • Are all ladders on site in good condition?

  • Has a daily pre-work inspection been completed of all ladders in use, and is the inspection noted in the daily Safe Plan of Action or available on site?

  • Are A-frame ladders set up correctly with legs fully opened and locked in place?

  • Are extension ladders set up at the proper slope of 4:1?

  • Do extension ladders extend at least 36" above the landing level?

  • Are ladders only set up on stable and level ground?

  • Overall compliance with Ladder safety requirements:

  • Deficiencies Noted:

  • Deficiency
  • Describe deficiency:

  • Insert photo of non-compliant item

  • Describe remedial actions taken:

Electrical

  • Are overhead and underground electrical utilities located and clearly marked?

  • Are extension cord sets appropriate gauge for load?

  • Are construction rated GFCIs used on all circuits greater than or equal to 120-volt, 15-20 amperes which are not connected to a building system?

  • Is all cord set insulation in good condition? No nicks or cuts or frays?

  • Do all cord sets have molded male and female end plugs with no gaps?

  • Are all cover plates in place on outlets?

  • Is any work occurring on live circuits greater than 50 volts AC or 100 volts DC?

  • What type of work is occurring?

  • Has the CM, PM or Site Manager designated a Qualified Person to perform live work?

  • A Qualified Person is one who has been designated by the CM, PM or Site Manager to perform electrical work, and who possesses the training and/or experience to perform the work safely.

  • What is the highest voltage or amperage personnel may be exposed to on live electrical circuits?

  • Only Qualified Electricians may perform work on live electrical equipment 480 volts or greater. A Qualified Electrician is defined as a licensed electrician or an employee who possess the experience and education necessary to properly and safely perform the work, and has been designated as Qualified Electrician and is authorized by the CM, PM or Site Manager to perform electrical work according to the requirements of the National Electrical Code, NFPA and the Jacobs HSEP 19.4 - Energized and Potentially Energized Electrical Equipment. .

  • Were efforts made to de-energize the circuits or electrical equipment to be worked on, as required by OSHA, NFPA, and Jacobs?

  • Has the effort to confirm that all alternate solutions and scheduling options for de-energizing the system have been considered and found not feasible been documented?

  • Has an Arc Flash Hazard Analysis been conducted on the potential exposures and/or have the specific hazards been identified and a control plan put in place?

  • Has the electrical safety checklist been completed and made available on site?

  • Are work areas clearly marked and barricaded from unauthorized entry?

  • Are electricians wearing appropriate PPE for the task and potential hazard in accordance with NFPA 70E Table 130.7(C)(9)(a) and Table 130.7(C)(10)?

  • Are all hand tools voltage-rated insulated tools?

  • Is a Permit system being used to authorize preparations and work on live circuits?

  • Overall Compliance with electrical safety requirements:

  • Deficiencies Noted:

  • Deficency
  • Describe deficiency

  • Insert photo of deficiency, if applicable.

  • Document remedial actions taken:

Excavations and Civil Work

  • Does the scope of work on site include excavation?

  • Tap to enter information
  • Name of Competent Person for excavations on site:

  • Is the equipment operator Qualified to operate excavation equipment?

  • Are designated safe walk paths or No Pedestrian zones established?

  • Are back-up alarms functioning on all mobile equipment?

  • Has the Pre-Excavation checklist been completed and made available on site?

  • Are overhead and underground utilities identified and clearly marked?

  • Are spoils piled at least 2-feet from the edge of the excavation?

  • Tap to enter information

  • Is there potential that personnel may enter the excavation while it is open?

  • How deep will the excavation be at its deepest point?

  • Is a safe means of ingress and egress provided at least every 25-feet?

  • Safe means of ingress and egress is defined as a ladder, steps or ramp.

  • Will the excavation exceed 5-feet deep at any point?

  • Indicate means to prevent trench collapse:

  • Describe other means of preventing trench collapse:

  • Does the scope of work include other civil work?

  • Tap to enter information
  • Describe other civil work:

  • Does the scope of work include use of heavy equipment or other motorized equipment?

  • Tap to enter information
  • What type of equipment is being used on site?

  • Is the operator trained and qualified to operate the equipment?

  • Is the operator operating the equipment safely?

  • Is the equipment inspected and in good condition?

  • Are there any hydraulic fluid or fuel leaks visible on the equipment?

  • Are the back up alarms functional and audible?

  • Are the seatbelts functional?

  • Are operators wearing seat belts at all times equipment is in motion?

  • Overall compliance with trenching and excavation requirements:

  • Deficiencies Noted:

  • Deficiency
  • Describe Deficiency:

  • Insert photo of deficiency, if applicable.

  • Document remedial actions:

Conclusions

  • Amount of time spent on site during visit:

  • Were all deficiencies corrected immediately?

  • Describe deficiencies yet to be corrected and time frame for abatement:

  • Deficiency
  • Deficiency yet to be corrected:

  • Time frame for abatement:

  • Is there a need to follow up with written documentation?

  • Describe documentation needed, responsible person and time frame expected for completion.

  • Documentation Needed
  • Documentation:

  • Person Responsible:

  • Date for required completion:

  • Comments:

  • Report Reviewed With:

  • List the crew members names that are on site during audit process

  • Signature of Person Completing Audit:

  • Signature of Site Foreman

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