Title Page

  • Conducted on

  • Prepared by

  • Branch Location/Job Name/Employee
  • Client / Site

  • Mechanics Name

Safety Documentation:

  • Does Employee have a safety manual?

  • Has a Job Hazard Analysis been completed and discussed with all Employees on site?

  • Are the applicable F.P.P.checked off and incorporated into the JHA<br> Personal Protective Equipment<br> Lock-Out/Tag-Out/Try-Out<br> Jumpers<br> Live Electrical Troubleshooting<br> Mechanical Stored Energy<br> Cartop and Pit Access<br> Barricades<br> Fall Protection<br> False Cars and Running Platforms<br> Hoisting and Rigging<br>

  • Are the applicable 5 Behavioral Safety Traps checked off and incorporated into the JHA<br> Lack of Awareness<br> Diminishing the Risk<br> Lack of Concentration<br> Unintentional Pressure<br> Fear Factor<br>

Clothing & Personnel Equipment:

  • Are Employees wearing proper footwear?

  • Are safety glasses being worn?

  • Is the Proper PPE being used as required for work being performed?

  • Does employee have Arc rated gloves and sleeves available for immediate use?

Electrical Safety:

  • Are all power cords in use plugged into GFCI?

  • Are all cords serviceable and grounded?

  • Is TKE jumper policy being followed completely including only authorized & registered jumper use?

  • Are meter and leads properly rated per TKE Policy (Category III, 1000V)?




  • Are energy sources locked & tagged out as required by TKE lockout policy?

  • Does employee have personal lock, hasp & tag available?

  • Are all damaged & defective tools, power cords, ladders & hoisting equipment tagged "Out of Service"?

Fall Protection:

  • Are employees tied off when required by TKE policy?

  • Have employees discussed the fall protection plan for the jobsite?

  • In the event of an employee falling into their PFAS, has a rescue plan been discussed?


  • Are proper barricades being used per TKE policy?

Fire Protection:

  • Could employee find their way out safely if they could not see?

  • Is employee following fire regulations regarding storage of flammables & combustibles?

First Aid:

  • Are adequate first aid supplies on hand?

Hand & Power Tools:

  • Are all tools in good condition?

Hazard Communication:

  • Are SDS's available on site for all chemicals and cleaners?

  • Are all containers and chemicals clearly marked with contents?


  • Are work areas kept free of slip and trip hazards?

  • Are work areas free of puncture and laceration hazards?


  • Are work areas illuminated enough to work safely?


  • Are portable ladders in good condition & with non-metal side rails?

  • Are ladders being used properly & for all access over 19" when stairs or ramp are not provided?

Hoisting Equipment:

  • Are all hoisting devices on site marked with rated capacity?

  • Have all employees on site received proper training for the equipment to be used?

  • Do we know the capacities of any building components used for hoisting?

  • Is all hoisting equipment & rigging in good condition? (hoists, hooks, clamps, shackles & slings)

  • Have all chain falls & chain hoists been certified within the last year?

  • Is the weight of the material to be lifted been verified?

Material Handling:

  • Are proper lifting techniques being followed? (back vertical / lifting with legs)

  • Are material handling dollies and hand trucks in good condition? (wheels, handles, etc.)

  • Is the path of travel free of obstructions?

  • Is the weight of the material to be moved been verified?

Are there any OTHER UNSAFE CONDITIONS, equipment or actions? If yes, explain below. N/A if there are none

  • Comment:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.