Title Page

  • Conducted on

  • Prepared by

  • Location

Project Information

  • Project Name and Number

  • Project Location
  • Select date

  • # Crew Present

Brief Description of Work Being Performed

PPE (Review Health & Safety Plan for Job Specific Requirements)

  • Hand Protection

  • Head Protection

  • Reflective Vest

  • Foot Protection

  • Eye Protection

  • Hearing Protection

  • Other (specify)

  • Specify other PPE Here

Body Use and Positioning

  • Body Positioning

  • Hands and Body Clear of Pinch Points

  • Other (Specify)

  • Specify other Body Use and Positioning Comments Here


  • Safe Parking Location

  • Tools and Equipment Properly Secured

  • Windows and Mirrors Free of Debris/Cracks

  • Proper Tire Tread Inflation (visible observation)

  • Other (Specify)

  • Specify Other Vehicle Comments Here

Safety Controls

  • First Aid Kit

  • Fire Extinguisher

  • Potable Water Supply

  • Bug Repellent

  • Sun Screen/Coverage

  • Project Health & Safety Plan Available On-Site

  • Tailgate Meeting Conducted/Documented

Job Site

  • Proper Lighting

  • Good Housekeeping

  • Clear Ingress/Egress


  • Machine Guards in Place

  • Proper Tools Used and In Good Condition

  • Hazardous Material Stored and Labeled Properly

  • Other (Specify)

  • Specify other Tools and Equipment Comments here.


  • Positive Comments

  • Comment on Additional Safety Controls or Other Improvements Needed

  • Add photo record of site conditions or other relevant safety observations on project.


  • Observer Name and Title

  • Field Work Supervisor Name & Title:

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.