Information
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Site:
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Forman:
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Conducted on:
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Prepared by:
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Project scope and general comments:
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Document No.
Site Conditions
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Un-level landscaping around building.
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Precautions have been made to control hazard (relocate ladder, use ladder leveler, etc.)
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Deck or other building obstructions.
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Precautions have been made to control hazard (relocate ladder, use ladder leveler, etc.)
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Overhead power lines above or near building.
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Precautions have been made to control hazard (de-energize line, line covered by utility company, crew keeps at least 10 feet of clearance, etc.)
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Ice or snow around ladder/roof access area.
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Precautions have been made to control hazard (snow and ice cleared, sand/snowmelt applied, etc.)
Site Safety Plan
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Written safety plan on site.
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Safety plan is:
General and Emergency Response Provisions
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First aid kits available and stocked.
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Water and restroom facilities available.
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First aid trained personnel on site if medical services are not available within 4 minutes.
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Fire extinguishers available on each floor and near flammable liquids in storage or in use.
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Fire extinguishers appear functional, free of damage, and inspected within the last 12 months.
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SDSs on site for chemicals present.
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Chemical containers properly labeled.
Housekeeping
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Debris picked up.
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Work areas free of trip hazards.
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Materials properly stored.
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Other housekeeping observations or comments.
Material Handlng
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Roller carts used for moving rolled roofing.
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Two-person lifting is used where roller carts are not feasible to move rolled roofing (elevation changes, piping obstructions, etc.).
Electrical
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Temporary power GFCI protected.
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Extension cords appear to be in serviceable condition.
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Other electrical observations or concerns.
Personal Protective Equipment
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Eye protection
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Eye protection usage policy.
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Eye protection worn as required.
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PPE appears to meet ANSI Z87 requirements and is in serviceable condition.
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Head Protection
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Head protection usage policy.
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PPE worn as required.
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PPE appears to be in serviceable condition.
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PPE is worn correctly (suspension in the proper direction, no ball caps under hard hat, etc.)
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High Visibility Clothing
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High visibility clothing usage policy.
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ANSI rating
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High visibility clothing worn as required.
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High visibility clothing appears to be in serviceable condition (clean, zipped up, etc.)
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Hearing Protection
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Noise monitoring assessments performed to determine worker exposure.
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Noise monitoring should be performed to assess average noise exposures to workers over an 8-hour time-weighted average. Pinnacol Assurance can provide this service at no cost to you. To request noise monitoring or other safety and industrial hygiene services, please contact Pinnacol's Safety on Call line at 303-361-4700.
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Assessment found noise exposures to be:
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Company has developed and implemented a written Hearing Conservation Program (HCP).
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Employees in HCP receive baseline and annual audio metric testing.
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Employees have been trained on HCP and use of hearing protection.
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Respiratory Protection
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Respirator usage is voluntary.
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Voluntary respirator use limited to filtering face piece respirators (disposable dust masks).
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Voluntary use respirators are NIOSH approved.
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Workers who wear filtering face piece respirators voluntarily have received Appendix D of OSHA's respiratory protection standard.
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Workers who voluntarily wear filtering facepiece respirators (dust masks) should be provided with a copy of the information below.
29 CFR 1910.134 - Appendix D - Information for Employees Using Respirators When Not Required
Respirators are an effective method of protection against designated hazards when properly selected and worn. Respirator use is encouraged, even when exposures are below the exposure limit, to provide an additional level of comfort and protection for workers. However, if a respirator is used improperly or not kept clean, the respirator itself can become a hazard to the worker. Sometimes, workers may wear respirators to avoid exposures to hazards, even if the amount of hazardous substance does not exceed the limits set by OSHA standards. If your employer provides respirators for your voluntary use, of if you provide your own respirator, you need to take certain precautions to be sure that the respirator itself does not present a hazard.
You should do the following:
1. Read and heed all instructions provided by the manufacturer on use, maintenance, cleaning and care, and warnings regarding the respirators limitations.
2. Choose respirators certified for use to protect against the contaminant of concern. NIOSH, the National Institute for Occupational Safety and Health of the U.S. Department of Health and Human Services, certifies respirators. A label or statement of certification should appear on the respirator or respirator packaging. It will tell you what the respirator is designed for and how much it will protect you.
3. Do not wear your respirator into atmospheres containing contaminants for which your respirator is not designed to protect against. For example, a respirator designed to filter dust particles will not protect you against gases, vapors, or very small solid particles of fumes or smoke.
4. Keep track of your respirator so that you do not mistakenly use someone else's respirator. -
Respirator use is mandatory.
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Respiratory hazard requiring protection:
- Dust
- Silica
- Acid
- Organic vapors
- Asbestos
- Other (explain below)
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Air monitoring has been conducted to determine and quantify hazard.
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Air monitoring should be performed to assess average exposures to workers over an 8-hour time-weighted average in order to determine if respiratory protection is required and if so, what type. Pinnacol Assurance can provide this service at no cost to you. To request air monitoring or other safety and industrial hygiene services, please contact Pinnacol's Safety on Call line at 303-361-4700.
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Written respiratory protection program in place.
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If company operations expose employees to atmospheres containing potentially dangerous concentrations of airborne contaminants (dust, chemical vapors/mists, fumes, etc.), respiratory protection may be required. If so, the company should develop and implement a formal respiratory protection program containing the following elements:
- Procedures for selecting respirators for use in the workplace.
-Medical evaluations of employees required to use respirators.
-Fit testing procedures for tight-fitting respirators.
-Procedures for proper use of respirators in routine and reasonably foreseeable emergency situations.
-Procedures and schedules for cleaning, disinfecting, storing, inspecting, repairing, discarding, and otherwise maintaining respirators.
-Procedures to ensure adequate air quality, quantity, and flow of breathing air for atmosphere-supplying respirators.
-Training of employees in the respiratory hazards to which they are potentially exposed during routine and emergency situations.
-Training of employees in the proper use of respirators, including putting on and removing them, any limitations on their use, and their maintenance.
-Procedures for regularly evaluating the effectiveness of the program.
A sample respiratory protection program can be obtained by contacting Pinnacol’s Safety on Call line at 303-361-4700. -
Workers required to wear respirators have been medically evaluated.
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Workers required to wear respirators have been fit tested.
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All respirators are NIOSH approved.
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Respirators in use:
- Filtering facepiece
- Half mask cartridge
- Full mask cartridge
- Powered-air purifying
- Supplied air
- Self contained breathing apparatus
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Respirators in use: N99 - Non-oil particulate - 99% efficient
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Respirators in use: N95 - Non-oil particulate - 95% efficient
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Respirators in use: R95 - Up to 8 hours with oil based particulates - 95% efficient
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Respirators in use: R99 - Up to 8 hours with oil based particulates - 99% efficient
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Cartridges in use: Magenta - HEPA (P100 - 99.97% efficient)
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Cartridges in use: Black - organic vapor
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Cartridges in use: White - acid gas
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Cartridges in use: Yellow - organic vapor and acid gas
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Cartridges in use: Olive - mercury vapor and chlorine
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Cartridges in use: Green - ammonia and methylamine
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Cartridges in use: Other
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Other cartridges in use:
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Respirators and cartridges (if applicable) are appropriate for the hazard.
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Other PPE concerns or comments.
Ladders
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Ladders on site.
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Ladders are of appropriate duty rating for the task.
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For construction operations, all ladders should be either Type 1, Type 1A, or Type 1AA
Ladder Type Rated Capacity Duty Rating Description
Type IAA Ladder 375 lb. Extra-heavy-duty industrial ladder
Type IA Ladder 300 lb. Heavy-duty industrial ladder
Type I Ladder 250 lb. Heavy-duty industrial ladder
Type II Ladder 225 lb. Medium-duty commercial ladder
Type III Ladder 200 lb. Light-duty household ladder
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Ladders are of proper type and size for the task.
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Ladders appear to be in serviceable condition.
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Ladders set up correctly (4:1 ratio, 36" extension past upper landing, etc).
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Other ladder concerns.
Scaffolding
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Scaffolding on site.
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Firm footing, mud sills, and base plates in place.
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Scaffold is plumb, square, and level.
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Cross braces are complete.
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Working levels are fully planked.
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Planks either overlap support 6-12" or are cleated to restrain from sliding (6-18" if planks are over 10').
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Plank deflection does not exceed 1/60 of the plank length, indicating overload. (1" deflection per 5' feet of plank length).
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Planking in serviceable condition.
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Front edge of platforms are no further than 14" from face of wall (18" for plastering operations).
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Scaffold access and egress is provided and adequate.
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If height is over 4 times the narrowest base dimension, scaffold is tied/braced to the wall.
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Scaffold ties installed per manufacturer spec or every 26 feet vertically and every 30 feet horizontally.
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Scaffolds with cantilevered work platforms are tied, braced, or outrigged to prevent tipping.
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Cantilevered work platforms are used to support workers only and not to store/stage materials.
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Fall protection over 10 feet is provided via guardrails or PFASs.
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Other scaffolding concerns?
Working at Heights
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Workers more than 6' above a lower level.
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PFAS
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Anchors appear adequate and/or properly installed.
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Lifelines in good condition and adjusted to restrain or limit free fall to 6 feet.
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Lanyards in good condition and properly connected.
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Harnesses in good condition and properly adjusted.
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Guardrails
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Rails are complete along fall hazard.
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Appear to be installed to withstand 200 pounds downward and outward force.
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42' top rail and 21" mid rails.
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Toe boards in place as needed to protect workers below from falling objects.
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Warning lines (Low slope (up to 4:1) roofing operations only)
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Warming lines complete around unprotected roof edge.
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Warning lines no closer than 6 feet from roof edge. <br>(10 feet if mechanical equipment is used perpendicular to warning line)
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Access point is blocked off by rope, chain, or other barricade, or the path is offset to avoid walking directly into the work area.
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Lines between 34 and 39 inches.
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Warning line stanchions appear capable of resisting 16 pound force applied 30 inches up.
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Workers between line and roof edge protected by PFAS or safety monitor.
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Safety monitor (Roofing operations or as part of a site-specific Fall Protection Plan only)
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Monitor is on same working level as workers, within sight distance, and close enough to communicate.
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Monitor warns workers when back is to roof edge or worker is pilling material in direction of roof edge.
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Monitor has no other duties to distract from monitoring workers.
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Site-specific Fall Protection Plan (Leading edge, precast concrete, and residential construction only)
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Conventional fall protection methods have been demonstrated to be I feasible.
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Plan is in writing and on site for review.
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Plan includes discussion of measures to be taken to protect workers who cannot use conventional fall protection methods.
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Plan includes names of workers included under the plan.
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Plan lists each location that conventional fall protection cannot be used. Locations are classified as Controlled Access Zones.
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Other fall protection concerns or comments.
Hand and power tools
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Hand and power tools in use.
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Hand tools in serviceable condition.
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Power tools properly guarded and free of damage.
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Power tools either grounded or double insulated.
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Other tool observations or comments.
Cranes and Rigging
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Company performing rigging operations.
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Riggers are trained in safe rigging principles.
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Riggers have reasonable idea of load weights (shipping docs, mfg specs, raw material calculations, etc.)
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Signal person has been trained and evaluated by the employer or qualified 3rd party and understands how to give and read signals, has a basic understanding of equipment limitations, understands relevant OSHA crane standard requirements, and has demonstrated qualification via oral, written, or practical testing.
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Documentation of signal person qualification on site.
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Rigging equipment is in serviceable condition (capacities labeled, free of damage, kinks, stains, etc.)
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Observed rigging practices appear effective and safe. <br>- tag lines used where appropriate<br>- no workers under suspended loads<br>- loads appear stable<br>- rigging equipment appears to be used per intended use and with its capacity
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Other rigging concerns.
Sign-off
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Evaluator's signature
