Information
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Project Name
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Conducted on
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Prepared by
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Location
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Personnel/Subs on Site
Personal Protective Equipment (PPE)
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Hard Hats
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Hearing Protection
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Respiratory Protection
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Proper Work Attire
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Proper Footwear
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Hand Protection
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Eye / Face Protection
Housekeeping
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Access & Egress Clear (Stairs, Isles, Walkways)
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Material Properly Stacked / Stored
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Debris / Trash Removal
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Nails - Bent / Removed
Ladders / Stairs
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Stair Railings / Hand Rails / Pan Fillers
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Secured / Tied Off
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Extends 3' Above Landing
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Proper Use / Corral at Top
Fall Protection
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Guardrail / Mid-Rail / Toe board / Perimeter cable
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Floor Hole Covers / Secure / Labelled
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Personal Fall Arrest / Fall Restraint / Proper design / Swing Fall
Scaffolding / False Work / Shoring / Decking / Concrete
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Planks / Decks / Platforms Installed Properly
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Impalement Protection / Rebar Caps / Troughs
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Proper Access / Ladder / Inspection
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Proper Bracing / Re-Shore / Pads
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Inspected / Secured / Structurally Sound
Electrical
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Adequate Lighting - Task / Area
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Grounding / Inspection / GFCI Use
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Cords Elevated / Receptacles / Plugs / Inspected
Fire Protection / Prevention
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Adequate Extinguishers (Area & Task) / Inspected / Nearby
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Flammable Materials Storage
Tools - Hand & Power
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Good Condition / Inspected
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Guarded / Guards in Place
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Used Properly
Site / Public Protection
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Barricading / Fences / Pedestrian Canopy
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Adequate Signage / Lighting
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Traffic Control Plan / Flagging
Emergency Preparedness / First Aid
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Emergency phone numbers posted
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First Aid Kits / Supplies
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Adequate Sanitation / Hand washing / Water
Programs / Information / Right to Know
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Safety Orientation held for Sub
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All required signage posted
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"No Trespassing"
Underground / Overhead / Confined Space
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Confined Spaces - Identified / Training / Permits
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Excavations / Trenches barricaded - Shoring / Benching / Sloping / Access / PE > 20'
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Equipment / Material At least 10' from Powelines
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Additional comments or safety concerns?
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Photos to document safety concerns
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Signature