Information
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Project/Job #
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Project/Job Name
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Conducted on
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Prepared by
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Project/Job Location
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Field Personnel
Work Zone
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General Housekeeping
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Walking/Working Surface
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Unprotected Sides or Holes
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Impalement Hazards
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Sanitary Facilities
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Trash Receptacles
Tool & Material Storage/Lay Down Area
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Tool Trailer
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Conex Box
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Gang Box
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Material Storage/Lay Down Area
Personal Protective Equipment
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Hard Hats
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Safety Glasses (Side Shields)
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Face Shield/Goggles (If Required)
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Respiratory Protection (If Required)
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Hearing Protection (If Required)
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Clothing (FRC etc. if Required)
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Gloves
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Foot Protection
Fall Protection
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Is Fall Protection Being Used
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Worn Properly
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Suitable Anchorage Point
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Stored Properly
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Emergency Rescue Plan
Ladders
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Is a Ladder Being Used?
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Base/Footing/Set Up
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Proper Type for Task
Tools & Equipment
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In Good Working Condition
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Whip-Checks (If Needed)
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GFCI/Double Insulated Tools
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Other
Excavations
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Is Work Being Performed in/around an Excavation?
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Access/Egress
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Soil Condition
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Water Accumulation
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Shoring/Shielding/Sloping
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Barricades
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Spoil Pile
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Air Monitoring
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Emergency Rescue Plan
Confined Space
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Is Work Being Performed in a Confined Space?
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Permit Required
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Permit Followed
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Attendant/Hole Watch
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Entrant Sign In Sheet
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Air Monitoring
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Emergency Rescue Plan
Electrical
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G.F.C.I
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Extension Cords
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Power Tools
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Lock Out/Tag Out
Fire Safety
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Hot Work Permit (If Required)
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Trained Fire Watch
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Fire Extinguisher Inspected
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Combustibles Removed/Isolated
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Hot work Barricade (If Required)
Rigging & Hoisting
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Capacity Tags
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Hooks & Latches
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Chain Falls/Come-a-Longs
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Tag Lines
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Designated Qualified Rigger
Scaffold
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Is Scaffold Being Used?
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Hand & Mid-rails/Toeboards
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Platform Decked/Secured
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Level Footing/Set Up
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Access/Egress
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Away from Powerlines
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Barricades (If Needed)
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Inspected/Tagged Correctly
Crane
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Is a Crane Being Used?
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Inspected
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Operator Manual
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Proper Setup
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Swing Radius
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Flagman with Vest
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Designated Qualified Signal Person
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Lift Plan (If Required)
Equipment
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Inspected
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Operator Qualified and Certified
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Operator Manual
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Flagman with Vest
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Proper Setup and Use
Chemicals
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GHS/HAZCOM Training
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SDS on Site
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SDS for all Chemicals
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Proper Storage of all Chemicals
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Proper PPE for Handling Chemicals
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HMIS/NFPA Labeling
Other
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A.
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B.
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C.
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D.
Comments/Recomendations
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Additional Comments/Recomendations
Sign Off
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Safety representative
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Field Rep
