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 documented as required?

  • 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?

  • Are proper gloves being worn?

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

Machine Room:

  • Is there safe access to the machine room?

  • Is the work area clear and clean of debris?

  • Is the area properly illuminated?

  • Are all guards in place, holes properly covered?

  • Does the Machine Room have a properly sized and rated fire extinguisher certified within 12 months?

Electrical Safety:

  • Are all power cords in use plugged into GFCI?

  • Are extension cords & drop light cords in good condition including ground prong?

  • Are drop lights properly guarded and are flashlights non-conductive?

  • Are all power tools and chargers either double insulated or with a ground prong?

  • Is employee following proper live electrical and troubleshooting procedures?

  • 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 tagged "Out of Service"?

Fire Protection:

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

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

Hoistway Procedures:

  • Can employee demonstrate proper hoistway access procedures?

  • Are all pit ladders accessible without putting TKE employee at risk?

  • Is proper Hoistway illumination available and functioning?

  • Is there a functioning car top inspection station?

  • Are pipe stands available on site?

  • Are proper barricades in place as required?

  • Prior to entering, did employee confirm car top / pit clear of oil and debris?

  • Upon exit, are all covers and guards returned to proper position?

Fall Protection:

  • Are employees tied off when required by TKE policy?

First Aid:

  • Are adequate first aid supplies on hand?

  • Does employee know how to identify blood borne pathogens and where they might be found?

  • Does employee know how to protect themselves from contaminated sources?

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 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?

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.)

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.