Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Location

Untitled Page

1. Housekeeping

  • Project work areas are clean and free of excess trash, debris

  • Walkways and passageways clear

  • Material or Equipment properly stored

  • Electrical cords, hoses, welding leads, elevated to prevent trip hazards

  • Scrap material free of protruding nails or other puncture hazards

  • Trash receptacles are provided for work areas and water kegs

  • Barricades, and/or rebar caps installed and maintained

  • Washrooms available and clean

  • Comments/Corrective Actions

2. Fall Protection

  • Body harness required and worn in a proper manner

  • Lanyards are adequately secured to suitable anchorage

  • Fall protection equipment is used only for fall protection

  • Fall protection maintained and has current inspection

  • Fall Protection Plan in place where required

  • Comments/Corrective Actions

3. Tools and Equipment Protection

  • Electrical cables are off the ground

  • Tools are maintained in a safe condition

  • Tools are properly carried and stored

  • Pneumatic/Hydraulic hose connections secured (whip checks)

  • Proper tools used for the job performed

  • Comments/Corrective Actions

4. Fire Protection

  • Flammables stored properly

  • Oxygen and combustibles separated

  • Containers labeled as per contents

  • Fire extinguishers properly located and inspected

  • Compressed gas cylinders properly maintained

  • Containment of hot work and welding screens as required

  • Comments/Corrective Actions

5. Human/Construction Traffic Interface

  • A local traffic management plan for this area

  • Dedicated pathwas for pedestrians to separate from vehicle routes

  • Posted speed signs

  • Spotters used in congested/high risk areas

  • Barriers to separate work areas from vehicle traffic

  • Comments/Corrective Actions

6. On-Site Field Personnel

  • Supervision and safety present at work site

  • All have completed orientation

  • New works identified

  • Comments/Corrective Actions

7. Personnel Protective Equipment

  • Hard hats worn and maintained

  • Hearing protection worn as required

  • Eye protection required and worn

  • Proper foot protection worn for job performed

  • Face Shield or goggles work as required

  • Comments/Corrective Actions

8. Excavations

  • Sloped and shored properly allowable slope

  • Materials or equipment at least 2 feet (0.68 meters) from the edge of the excavation

  • Access and egress provided at appropriate intervals

  • Comments/Corrective Actions

9. Scaffolds and Ladders

  • Proper access and egress provided

  • Tagged correctly

  • Proper ladder for the job performed/properly secured

  • Comments/Corrective Actions

10. Hoisting and Rigging Equipment

  • Chains falls, come-a-longs, chokers in good condition with current inspection

  • Softeners used as required

  • Tag lines used

  • Comments/Corrective Actions

11. Vehicles/Mobile Equipment

  • Lights, brakes, horns, alarms working properly

  • Seat belts provided and used

  • Inspections completed

  • Back-in policy compliant

  • Comments/Corrective Actions

12. Permits/Safety Task Assignment/JSA/Workplans

  • Applicable permits posted

  • Current STA/FLRA with each crew

  • JSA is referenced on the STA/FLRA

  • Lift Plans and Critical Lift Plan is in place where required

  • Comments/Corrective Actions

Items

  • Needs Attention/Stop Work Items

  • Action Taken

  • Closed?

  • Remarks

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.