Information
-
Document No.
-
Audit Title
-
Client / Site
-
Conducted on
-
Prepared by
-
Location
-
Personnel
1. Safety Administration
-
A) State Minimum Wage Compliance Poster-Posted
-
B) Occupational Safety and Health Act (OSHA) Poster-Posted
-
C) Equal Employment Opportunity (EEO) Poster-Posted
-
D) Family Medical Leave Act (FMLA) Poster-Posted
-
E) Employee Polygraph Protection Act (EPPA) Notice-Posted
-
F) Uniformed Services Employment and Reemployment Rights Act (USERRA) Notice/Poster-Posted
-
G) Employee Orientation Forms on File - Available Electronically
-
H) Form 300 Posted From February 1st through to April 30
-
I) First Aid Kit Supplied-Stocked
-
J) Emergency Numbers Posted
-
K) State Group Safety and Loss Prevention Manual Available
-
L) Toolbox Meetings and Inspection Book
-
M) Job Hazard Analysis
-
N) Other
2. Housekeeping
-
A) Work Areas Clean and Free of Excess Trash and Debris
-
B) Adequate Lighting
-
C) Passageways & Walkways Clear
-
-
D) Other
3. Fire Prevention
-
A) Extinguishers-Clip, Seal, Charged, Inspection Tag
-
B) Flammable Stored Properly
-
C) Approved Safety Can With Screens
-
D) Other
4. Personal Protective Equipment
-
A) Hard Hat, Safety Glasses, Steel/Metatarsal Boots
-
B) Hearing Protection
-
C) Respiratory Protection
-
D) Chemical Suits
-
E) Other
5. Confined Space
-
A) Permit Required or Non-Permit Required
-
B) Air Monitored
-
C) Emergency Equipment
-
D) Other
6. Equipment Operations
-
A) Loads Secured
-
B) Seat Belt and Back Up Alarms
-
C) Daily, Monthly, and Annual Inspection
-
D) Lift Permit
-
E) Valid Driver's License
-
F) Other
7. Ladders
-
A) Good Condition
-
B) Secured in Walkways
-
C) Secured and Exceed Work Area 3'
-
D) Step Ladders Fully Open
-
E) No Standing on the Top 2 Rungs
-
F) Other
8. Stairways
-
A) Height of Handrails Between 30-37"
-
B) 4 Risers or 30" Sides Protected by Rail
-
C) Access Area Clear
-
D) Other
9. Material Handling And Storage
-
A) Materials Stored Properly
-
B) Aisles and Passageways Clear
-
C) Rigging Equipment Inspected
-
D) Other
10. Aerial Lifts
-
A) Daily Inspection
-
B) Fall Protection
-
C) Clear 10' from Energized Power Lines
-
D) Platform Clear of Tools, Materials, etc.
-
E) Other
11. Fall Protection
-
A) Guardrail System (top rail, mid rail, etc.)
-
B) Body Harness and Lanyard
-
C) Open Holes, Secured, & Identified
-
D) Other
12. Scaffolds
-
A) Fall Protection
-
B) Proper Access and Egress
-
C) Tags Identify Requirements of Use
-
D) Work Area Completely Planked/Secured
-
E) Guard Rails Needed 10'
-
F) Other
13. Welding and Burning
-
A) Hot Work Permit
-
B) Fire Extinguisher
-
C) Gas Bottles Properly Stored and Capped
-
D) Hot Slag and Sparks are Properly Maintained and Controlled
-
E) Proper PPE
-
F) Welding Cable and Ground Cable Properly Inspected
-
G) Other
14. Electrical
-
A) Electrical Panels Properly Marked
-
B) Lockout/Tagout/Tryout Procedure Used
-
C) High Voltage Gear is Provided and Inspected (Gloves, Blankets, Sticks)
-
D) GFCI
-
E) Temporary Lighting
-
F) Other
15. Hand Tools, Power Tools and Power Equipment
-
A) All Mechanical Safeguards in Use
-
B) Cords in Good Condition, Elevated, or Protected
-
C) Tools and Cords Inspected for Assured Grounding
-
D) Tools Maintained in a Safe Condition
-
E) Other
16. Excavations and Trenches
-
A) Daily Inspection
-
B) Ladder, Ramp, etc. for Access
-
C) 4' Shored or Sloped
-
D) Barricaded
-
E) Other
17. Signs and Barricades
-
A) Yellow Caution Tape
-
B) Red Danger Tape
-
C) Hard Barricade
-
D) Vehicular Traffic
-
E) Other
Non Conforming Issues - Countermeasure - Corrected By - Implementation Date
Additional Comments
-
Signature From Evaluator:
