M3 Insurance

• Client / Site

• Audit Title

• Document No.

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Field Safety Paperwork

• Daily Maintenance: Aerial Work Platform

  Yes

  No

  N/A

• Daily Maintenance: Skytrak

  Yes

  No

  N/A

• Daily Crew/Safety Huddle

  Yes

  No

  N/A

• Meeting Attendance: Safety/Toolbox Talks

  Yes

  No

  N/A

• Safety Assessment Form

  Yes

  No

  N/A

• Task-Specific Safety Plan

  Yes

  No

  N/A

• Excavation Permit

  Yes

  No

  N/A

• Confined Space Hazard Assessment

  Yes

  No

  N/A

• Confined Space Permit

  Yes

  No

  N/A

• Ventilation & Air Sampling

  Yes

  No

  N/A

• Hot Work Permit

  Yes

  No

  N/A

• Scaffolding Inspection

  Yes

  No

  N/A

• Critical Lift Permit

  Yes

  No

  N/A

Posters, Training, Communication

• Site Board visible and current

  Yes

  No

  N/A

• OSHA Notice / 300 Log Posted As Necessary

  Yes

  No

  N/A

• Location of nearest Occupational Clinic

  Yes

  No

  N/A

• Stretching/Daily Warmup

  Yes

  No

  N/A

• GHS Information Posted

  Yes

  No

  N/A

First Aid and Emergency

• Stocked/Current First Aid Kit on-site

  Yes

  No

  N/A

• Crisis Management Program on-site

  Yes

  No

  N/A

• Stokes Basket on-site and accessible

  Yes

  No

  N/A

PPE

• Hardhat, Safety Glasses, Proper Boots

  Yes

  No

  N/A

• FR Clothing

  Yes

  No

  N/A

• High Visibility Clothing as Required

  Yes

  No

  N/A

• Respiratory protection used as necessary

  Yes

  No

  N/A

• Hearing protection used as necessary

  Yes

  No

  N/A

• Other PPE being used when necessary(face protection; gloves; specialty equipment; etc.)

  Yes

  No

  N/A

Fall Protection

• Proper fall protection at 6' or greater

  Yes

  No

  N/A

• Personnel below are protected from falling objects

  Yes

  No

  N/A

• Controlled access zones used

  Yes

  No

  N/A

• Warning lines 6'-10' from edge

  Yes

  No

  N/A

• Wall opening guarded

  Yes

  No

  N/A

• Open sided floors or platforms 6' or more from lower level equipped with proper guardrail

  Yes

  No

  N/A

• Floor openings 2" or more properly barricaded/protected/secured/marked/covered

  Yes

  No

  N/A

• Hoisting Operations: Guardrails in place/replaced after each load received

  Yes

  No

  N/A

Stairways and Ladders

• Properly Inspected, in good condition, and marked appropriately

  Yes

  No

  N/A

• Properly Secured

  Yes

  No

  N/A

• Necessary labels visible and legible

  Yes

  No

  N/A

• Straight ladders extend 3' above landing area

  Yes

  No

  N/A

• Step ladder properly used

  Yes

  No

  N/A

• Guard rails provided for stairway landing areas

  Yes

  No

  N/A

• Handrails provided for stairways with 4 or more risers

  Yes

  No

  N/A

Scaffolding

• Properly erected and supervised by competent person

  Yes

  No

  N/A

• Properly tagged

  Yes

  No

  N/A

• Daily competent person inspection documented

  Yes

  No

  N/A

• Fall protection/prevention used at 10' and above

  Yes

  No

  N/A

• Scaffolding tied to structure 30' horizontally and 20' vertically

  Yes

  No

  N/A

• Scaffolding plumb, cross bracing in place

  Yes

  No

  N/A

• Fully planked and toe boards in place

  Yes

  No

  N/A

• Plank spacing is 1" or less

  Yes

  No

  N/A

• Plank extends 6" or more (or) plank ends cleated

  Yes

  No

  N/A

• Base plates and mud sills used as necessary

  Yes

  No

  N/A

• Ladder access provided

  Yes

  No

  N/A

Aerial Lifts

• Proper Use

  Yes

  No

  N/A

• Fall Protection required?

  Yes

  No

  N/A

• Has equipment been inspected, appropriately selected, and worn correctly?

  Yes

  No

  N/A

Concrete and Masonry

• Safe hoisting equipment

  Yes

  No

  N/A

• Masonry walls over 8' braced if required/applicable

  Yes

  No

  N/A

• Limited Access Zone established (height of wall >=4')

  Yes

  No

  N/A

• All protruded rebar guarded

  Yes

  No

  N/A

Excavations

• Competent person on-site

  Yes

  No

  N/A

• Daily/change in conditions competent person inspection documented (Excavation Work Permit)

  Yes

  No

  N/A

• Was one-call system contacted

  Yes

  No

  N/A

• Holes, trenches, excavations, etc. are identified and protected

  Yes

  No

  N/A

• Surface encumbrances protected/supported

  Yes

  No

  N/A

• Ladder or ramp within 25' of all employees in trenches 4' or greater in depth

  Yes

  No

  N/A

• Utilities protected/supported

  Yes

  No

  N/A

• Spoil piles minimum of 2' from edge of excavation

  Yes

  No

  N/A

• Overhead power lines minimum distance of 20'

  Yes

  No

  N/A

Motor Vehicles and Heavy Equipment

• Horn and backup alarm operable

  Yes

  No

  N/A

• Seat belts used

  Yes

  No

  N/A

• Job traffic controlled

  Yes

  No

  N/A

• Adequate signage for safe travel

  Yes

  No

  N/A

• Inspected and charged fire extinguisher on equipment

  Yes

  No

  N/A

• Weights and loads controlled

  Yes

  No

  N/A

Cranes, Rigging, Signal Person

• Certified and Qualified Crane Operator

  Yes

  No

  N/A

• Critical Lift Permit used as necessary

  Yes

  No

  N/A

• Lift Director on-site

  Yes

  No

  N/A

• Swing Radius Controlled

  Yes

  No

  N/A

• Power lines deactivated, removed, protected, or safe distance

  Yes

  No

  N/A

• Qualified Rigger/Signal Person

  Yes

  No

  N/A

• Rigging Inspection by competent person prior to use

  Yes

  No

  N/A

• Rigging Inspection Log maintained

  Yes

  No

  N/A

• Annual Chain Sling Inspection Documented

  Yes

  No

  N/A

Confined Space

• Declared Permit or non-permit

  Yes

  No

  N/A

• Rescue Plan communicated and understood

  Yes

  No

  N/A

• Air monitor on site (properly calibrated, properly used)

  Yes

  No

  N/A

• Atmosphere test results documented

  Yes

  No

  N/A

• Energy sources locked out/tagged out

  Yes

  No

  N/A

• Adequate ventilation

  Yes

  No

  N/A

Hot Work

• Hot-work permit completed/posted

  Yes

  No

  N/A

• Welding screens provided

  Yes

  No

  N/A

• Fire extinguisher present

  Yes

  No

  N/A

• Proper additional PPE provided

  Yes

  No

  N/A

• Equipment in good repair, insulators, grounding, welding leads

  Yes

  No

  N/A

• Adequate ventilation or respirator utilized

  Yes

  No

  N/A

• Fire watch provided 30 minutes post work

  Yes

  No

  N/A

Cylinders

• Compressed gas cylinders stored and secured upright

  Yes

  No

  N/A

• Empty gas cylinders marked

  Yes

  No

  N/A

• Stored properly

  Yes

  No

  N/A

• Cylinders capped

  Yes

  No

  N/A

Fire Protection & Prevention

• 1 fire extinguisher/3000sqft

  Yes

  No

  N/A

• Fire extinguisher within 50' of flammable liquids

  Yes

  No

  N/A

• Bulk fuel - labeled, grounded, and stored >25' from construction operations

  Yes

  No

  N/A

• Approved metal safety containers for gasoline and diesel

  Yes

  No

  N/A

• Flammable and explosive materials stored and handled safely

  Yes

  No

  N/A

• Required number of fire extinguishers are inspected and tagged

  Yes

  No

  N/A

• All vehicles & other mobile equipment provided with fire extinguisher

  Yes

  No

  N/A

Electrical

• Assured Grounding Program up to date

  Yes

  No

  N/A

• All electrical equipment in good condition

  Yes

  No

  N/A

• Lighting cords and wiring secured with NON-conductive material

  Yes

  No

  N/A

• Power tools are protected with GFCI or internal grounding

  Yes

  No

  N/A

• Pinch/drive-over hazards eliminated

  Yes

  No

  N/A

• Terminal boxes properly covered

  Yes

  No

  N/A

• Exposed light bulbs equipped with protective cage and bulbs in place

  Yes

  No

  N/A

• Good work practices (cords out of pathways, kept out of water, etc.)

  Yes

  No

  N/A

• Adequate Arc Flash Protection

  Yes

  No

  N/A

• Arc Flash Equipment inspected and in good condition

  Yes

  No

  N/A

Hand and Power Tools

• Guards in place

  Yes

  No

  N/A

• Safe work practices

  Yes

  No

  N/A

• Stored safely

  Yes

  No

  N/A

• Maintained properly and in good condition

  Yes

  No

  N/A

• Correct tool used/used for intended purpose

  Yes

  No

  N/A

Silica Exposure Control

• Table 1 controls fully and properly implemented

  Yes

  No

  N/A

• Equipment inspected and in good condition

  Yes

  No

  N/A

• Filters changed as necessary

  Yes

  No

  N/A

• Proper respiratory protection as necessary

  Yes

  No

  N/A

Housekeeping

• Clean and organized work trailers

  Yes

  No

  N/A

• Trash picked up and disposed of regularly

  Yes

  No

  N/A

• Walkways and passageways clear

  Yes

  No

  N/A

• Portable toilets/handwashing stations - adequate, cleaned, and serviced

  Yes

  No

  N/A

• Work areas neat and organized

  Yes

  No

  N/A

• No projecting nails/screws

  Yes

  No

  N/A

• Material stored in orderly and safe manner

  Yes

  No

  N/A

• Potable water available

  Yes

  No

  N/A

Other items found

• Yes

  No

  N/A

• Yes

  No

  N/A

Positive Insight

• Comments

  Yes

  No

  N/A

• Safety Representative

  Sign

• Superintendent

  Sign

• Foreman

  Sign