TRC - Safety Performance Review PPL

• Conducted on

  Date

• Prepared by

• Location
  Address

Project Information

• Project Name and Number

• Project Location
  Address

• Select date

  Date

• # Crew Present

Brief Description of Work Being Performed

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

• Hand Protection

  Select E=Exceptional S=Satisfactory NI=Needs Improvement N/A

  • E=Exceptional
  • S=Satisfactory
  • NI=Needs Improvement
  • N/A

• Head Protection

  Select E=Exceptional S=Satisfactory NI=Needs Improvement N/A

  • E=Exceptional
  • S=Satisfactory
  • NI=Needs Improvement
  • N/A

• Reflective Vest

  Select E=Exceptional S=Satisfactory NI=Needs Improvement N/A

  • E=Exceptional
  • S=Satisfactory
  • NI=Needs Improvement
  • N/A

• Foot Protection

  Select E=Exceptional S=Satisfactory NI=Needs Improvement N/A

  • E=Exceptional
  • S=Satisfactory
  • NI=Needs Improvement
  • N/A

• Eye Protection

  Select E=Exceptional S=Satisfactory NI=Needs Improvement N/A

  • E=Exceptional
  • S=Satisfactory
  • NI=Needs Improvement
  • N/A

• Hearing Protection

  Select E=Exceptional S=Satisfactory NI=Needs Improvement N/A

  • E=Exceptional
  • S=Satisfactory
  • NI=Needs Improvement
  • N/A

• Other (specify)

  Select E=Exceptional S=Satisfactory NI=Needs Improvement N/A

  • E=Exceptional
  • S=Satisfactory
  • NI=Needs Improvement
  • N/A

• Specify other PPE Here

Body Use and Positioning

• Body Positioning

  Select E=Exceptional S=Satisfactory NI=Needs Improvement N/A

  • E=Exceptional
  • S=Satisfactory
  • NI=Needs Improvement
  • N/A

• Hands and Body Clear of Pinch Points

  Select E=Exceptional S=Satisfactory NI=Needs Improvement N/A

  • E=Exceptional
  • S=Satisfactory
  • NI=Needs Improvement
  • N/A

• Other (Specify)

  Select E=Exceptional S=Satisfactory NI=Needs Improvement N/A

  • E=Exceptional
  • S=Satisfactory
  • NI=Needs Improvement
  • N/A

• Specify other Body Use and Positioning Comments Here

Vehicle

• Safe Parking Location

  Select E=Exceptional S=Satisfactory NI=Needs Improvement N/A

  • E=Exceptional
  • S=Satisfactory
  • NI=Needs Improvement
  • N/A

• Tools and Equipment Properly Secured

  Select E=Exceptional S=Satisfactory NI=Needs Improvement N/A

  • E=Exceptional
  • S=Satisfactory
  • NI=Needs Improvement
  • N/A

• Windows and Mirrors Free of Debris/Cracks

  Select E=Exceptional S=Satisfactory NI=Needs Improvement N/A

  • E=Exceptional
  • S=Satisfactory
  • NI=Needs Improvement
  • N/A

• Proper Tire Tread Inflation (visible observation)

  Select E=Exceptional S=Satisfactory NI=Needs Improvement N/A

  • E=Exceptional
  • S=Satisfactory
  • NI=Needs Improvement
  • N/A

• Other (Specify)

  Select E=Exceptional S=Satisfactory NI=Needs Improvement N/A

  • E=Exceptional
  • S=Satisfactory
  • NI=Needs Improvement
  • N/A

• Specify Other Vehicle Comments Here

Safety Controls

• First Aid Kit

  Select E=Exceptional S=Satisfactory NI=Needs Improvement N/A

  • E=Exceptional
  • S=Satisfactory
  • NI=Needs Improvement
  • N/A

• Fire Extinguisher

  Select E=Exceptional S=Satisfactory NI=Needs Improvement N/A

  • E=Exceptional
  • S=Satisfactory
  • NI=Needs Improvement
  • N/A

• Potable Water Supply

  Select E=Exceptional S=Satisfactory NI=Needs Improvement N/A

  • E=Exceptional
  • S=Satisfactory
  • NI=Needs Improvement
  • N/A

• Bug Repellent

  Select E=Exceptional S=Satisfactory NI=Needs Improvement N/A

  • E=Exceptional
  • S=Satisfactory
  • NI=Needs Improvement
  • N/A

• Sun Screen/Coverage

  Select E=Exceptional S=Satisfactory NI=Needs Improvement N/A

  • E=Exceptional
  • S=Satisfactory
  • NI=Needs Improvement
  • N/A

• Project Health & Safety Plan Available On-Site

  Select E=Exceptional S=Satisfactory NI=Needs Improvement N/A

  • E=Exceptional
  • S=Satisfactory
  • NI=Needs Improvement
  • N/A

• Tailgate Meeting Conducted/Documented

  Select E=Exceptional S=Satisfactory NI=Needs Improvement N/A

  • E=Exceptional
  • S=Satisfactory
  • NI=Needs Improvement
  • N/A

Job Site

• Proper Lighting

  Select E=Exceptional S=Satisfactory NI=Needs Improvement N/A

  • E=Exceptional
  • S=Satisfactory
  • NI=Needs Improvement
  • N/A

• Good Housekeeping

  Select E=Exceptional S=Satisfactory NI=Needs Improvement N/A

  • E=Exceptional
  • S=Satisfactory
  • NI=Needs Improvement
  • N/A

• Clear Ingress/Egress

  Select E=Exceptional S=Satisfactory NI=Needs Improvement N/A

  • E=Exceptional
  • S=Satisfactory
  • NI=Needs Improvement
  • N/A

Tools/Equipment

• Machine Guards in Place

  Select E=Exceptional S=Satisfactory NI=Needs Improvement N/A

  • E=Exceptional
  • S=Satisfactory
  • NI=Needs Improvement
  • N/A

• Proper Tools Used and In Good Condition

  Select E=Exceptional S=Satisfactory NI=Needs Improvement N/A

  • E=Exceptional
  • S=Satisfactory
  • NI=Needs Improvement
  • N/A

• Hazardous Material Stored and Labeled Properly

  Select E=Exceptional S=Satisfactory NI=Needs Improvement N/A

  • E=Exceptional
  • S=Satisfactory
  • NI=Needs Improvement
  • N/A

• Other (Specify)

  Select E=Exceptional S=Satisfactory NI=Needs Improvement N/A

  • E=Exceptional
  • S=Satisfactory
  • NI=Needs Improvement
  • N/A

• Specify other Tools and Equipment Comments here.

Comments

• Positive Comments

• Comment on Additional Safety Controls or Other Improvements Needed

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

  Media

Acknowledgement

• Observer Name and Title

• Field Work Supervisor Name & Title: