THA

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• TASK START DATE

  Date

• TASK END DATE

  Date

PROJECT INFORMATION

• PROJECT NAME

• DESCRIPTION OF WORK TO BE PERFORMED

• CONTRACTOR NAME

• LOCATION OF TASK

• CONTRACTOR SUPERVISOR NAME

• COMPETENT PERSON

EVALUATING YOUR WORK AREA

• Has the competent person performed required inspections?

  Yes

  No

  N/A

• Does the task require special training?

  Yes

  No

  N/A

• All training been verified - sticker - card?

  Yes

  No

  N/A

• Is air monitoring required?

  Yes

  No

  N/A

• Are work permits required for this task?

  Yes

  No

  N/A

• Should the safety department be involved?

  Yes

  No

  N/A

• Has emergency equipment been located?

  Yes

  No

  N/A

• Has your activity been coordinated with other crafts involved?

  Yes

  No

  N/A

• Are you familiar with evacuation routs of site?

  Yes

  No

  N/A

• Do you have required PPE needed for this task?

  Yes

  No

  N/A

• Are the required materials and tools provided?

  Yes

  No

  N/A

• Have all tools / equipment been inspected before use?

  Yes

  No

  N/A

• Is there a safety issue that has not been addressed?

  Yes

  No

  N/A

• Is a permit required / completed?

  Yes

  No

  N/A

• Are scaffold tags needed?

  Yes

  No

  N/A

• Is an MSDS review necessary for this task?

  Yes

  No

  N/A

POTENTIAL HAZARD CHECKLIST

• CAUGHT IN / BETWEEN

  Safe

  At Risk

  N/A

• PARTICLES IN EYES

  Safe

  At Risk

  N/A

• ELEVATED WORK

  Safe

  At Risk

  N/A

• POOR HOUSEKEEPING

  Safe

  At Risk

  N/A

• ELECTRICAL SHOCK

  Safe

  At Risk

  N/A

• EXCAVATIONS

  Safe

  At Risk

  N/A

• CAVE-INS

  Safe

  At Risk

  N/A

• LOCKOUT / TAGOUT

  Safe

  At Risk

  N/A

• INADEQUATE ACCESS TO DIFFERENT LEVELS OR FLOORS

  Safe

  At Risk

  N/A

• HIGH NOISE LEVELS

  Safe

  At Risk

  N/A

• STRUCK BY OBJECTS

  Safe

  At Risk

  N/A

• LIFTING (STRAINS)

  Safe

  At Risk

  N/A

• WEATHER

  Safe

  At Risk

  N/A

• EXPOSURE TO COLD

  Safe

  At Risk

  N/A

• EXPOSURE TO HEAT

  Safe

  At Risk

  N/A

• PLANT OPERATIONS

  Safe

  At Risk

  N/A

• MOVING MACHINERY

  Safe

  At Risk

  N/A

• MOBILE EQUIPMENT

  Safe

  At Risk

  N/A

• HAZARDOUS CHEMICALS

  Safe

  At Risk

  N/A

• INHALATION HAZARDS

  Safe

  At Risk

  N/A

• CHEMICAL BURN

  Safe

  At Risk

  N/A

• HEAT EXHAUSTION

  Safe

  At Risk

  N/A

• HEAT STRESS

  Safe

  At Risk

  N/A

• CRITICAL LIFT

  Safe

  At Risk

  N/A

• RIGGING

  Safe

  At Risk

  N/A

• LADDERS

  Safe

  At Risk

  N/A

• FALLS FROM ELEVATION

  Safe

  At Risk

  N/A

• SCAFFOLDING

  Safe

  At Risk

  N/A

• CONFINED SPACE

  Safe

  At Risk

  N/A

• COMPRESSED GAS

  Safe

  At Risk

  N/A

• OVERHEAD POWER LINES

  Safe

  At Risk

  N/A

• ENVIRONMENTAL - MOLD

  Safe

  At Risk

  N/A

• ENVIRONMENTAL - LEAD

  Safe

  At Risk

  N/A

• ENVIRONMENTAL - ASBESTOS

  Safe

  At Risk

  N/A

• ENVIRONMENTAL - SILICA

  Safe

  At Risk

  N/A

• ELEVATED LOADS

  Safe

  At Risk

  N/A

• TRIPS / SLIPS / FALLS

  Safe

  At Risk

  N/A

• BIO - HAZARDS

  Safe

  At Risk

  N/A

• MED GAS

  Safe

  At Risk

  N/A

• FIRE - OXYGEN / ACETYLENE

  Safe

  At Risk

  N/A

• CHEMICAL SPILLS IN WATER WAYS

  Safe

  At Risk

  N/A

• ABRASIONS / CUTS

  Safe

  At Risk

  N/A

• PINCH POINTS

  Safe

  At Risk

  N/A

• SAFETY GLASSES

  Yes

  No

  N/A

• SIDE SHIELDS

  Yes

  No

  N/A

PPE

• SAFETY GLASSES

  Yes

  No

  N/A

• SIDE SHIELDS

  Yes

  No

  N/A

• HARD HATS

  Yes

  No

  N/A

• RUBBER BOOTS

  Yes

  No

  N/A

• DUST MASK - RESPIRATORS

  Yes

  No

  N/A

• HIGH VIS VEST

  Yes

  No

  N/A

• FACE SHIELDS

  Yes

  No

  N/A

• EAR PLUGS

  Yes

  No

  N/A

• LEATHER GLOVES

  Yes

  No

  N/A

HAZ-COM

• EMPLOYEES TRAINED

  Yes

  No

  N/A

• MSDS AVAILABLE FOR TASK

  Yes

  No

  N/A

POWER TOOLS

• EXTENSION CORDS IN GOOD CONDITION

  Yes

  No

  N/A

• GFCI NEEDED

  Yes

  No

  N/A

• GUARDS IN PLACE

  Yes

  No

  N/A

LADDERS

• LADDER INSPECTED AND IN GOOD SHAPE

  Yes

  No

  N/A

• TIED OFF OR SECURED

  Yes

  No

  N/A

• EXTENSION LADDER USED

  Yes

  No

  N/A

• 4-1 RATIO USED WITH EXTENSION LADDER

  Yes

  No

  N/A

• STEP LADDER USED

  Yes

  No

  N/A

ENVIORMENTAL

• WATER CONTROLS IN PLACE

  Yes

  No

  N/A

• ICRA COMPLETED

  Yes

  No

  N/A

• ILSM COMPLETED

  Yes

  No

  N/A

• SPILL CONTAINMENT KIT IN PLACE

  Yes

  No

  N/A

• DUST CONTROLS

  Yes

  No

  N/A

• FUEL CONTAINMENT PLUGS IN PLACE

  Yes

  No

  N/A

FALL PROTECTION

• INSPECTED DAILY

  Yes

  No

  N/A

• ANNUAL INSPECTION TAG IN PLACE

  Yes

  No

  N/A

• WORKERS TRAINED IN FALL PROTECTION

  Yes

  No

  N/A

• HORIZONTAL LIFELINE NEEDED

  Yes

  No

  N/A

• VERSA CLAMP NEEDED

  Yes

  No

  N/A

• HARNESS NEEDED (HOW MANY?)

  Yes

  No

  N/A

• LANYARDS - TYPE?

  Yes

  No

  N/A

• RETRACTABLE NEEDED - QUANTITY -LENGTH - NUMBER

  Yes

  No

  N/A

• BEAM CLAMPS NEEDED

  Yes

  No

  N/A

• ROPE GRAB SYSTEM NEEDED

  Yes

  No

  N/A

ICRA

• NEGATIVE AIR MACHINES NEEDED - AMOUNT?

  Yes

  No

  N/A

• WALK OFF MATS NEEDED

  Yes

  No

  N/A

• NEGATIVE AIR MONITOR NEEDED?

  Yes

  No

  N/A

• PAPERWORK POSTED

  Yes

  No

  N/A

• DAILY INSPECTION FORMS

  Yes

  No

  N/A

TRAINING NEEDED FOR TASK

• WEIGAND ORIENTATION VIDEO

  Yes

  No

  N/A

• ICRA VIDEO

  Yes

  No

  N/A

• LULL TRAINING

  Yes

  No

  N/A

• AERIAL LIFT TRAININIG

  Yes

  No

  N/A

• CONFINED SPACE

  Yes

  No

  N/A

• SCAFFOLD - HYDRO - SWING STAGE - SINGLE MAN

  Yes

  No

  N/A

• FALL PROTECTION

  Yes

  No

  N/A

• QUALIFIED RIGGERS

  Yes

  No

  N/A

• QUALIFIED SIGNAL PERSON

  Yes

  No

  N/A

• SIGNATURE OF PERSON COMPLETING THIS FORM

  Sign

• SIGNATURE OF SUPERVISOR OF THIS TASK

  Sign

• SIGNATURE OF SAFETY DEPARTMENT REPRESENTATIVE

  Sign

• OTHER

  Sign