Job Safety Inspection Form Submission Date: 09/21/2023Inspector* First Last Job Number* Location* Site Foreman* Attention project managers and foreman of this job site, please go over this inspection with your crews and come up with a plan to correct any unsatisfactory areas ASAP.General Safety Items1. Employees participating in THA's?* Satisfactory Unsatisfactory Not Applicable Explain why*2. Is the public adequately protected from any danger pose by our work?* Satisfactory Unsatisfactory Not Applicable Explain why*3. Does the Foreman know the location of the nearest medical facility?* Satisfactory Unsatisfactory Not Applicable Explain why*4. First aid kit available?* Satisfactory Unsatisfactory Not Applicable Explain why*5. SDS sheets available?* Satisfactory Unsatisfactory Not Applicable Explain why*6. Flammable liquids properly labeled and stored in a safety can?* Satisfactory Unsatisfactory Not Applicable Explain why*7. Fire extinguisher 25'-75' from fuel barrel?* Satisfactory Unsatisfactory Not Applicable Explain why*8. Fire extinguishers available, inspected monthly, and maintained annually?* Satisfactory Unsatisfactory Not Applicable Explain why*9. Caps in place on concrete pins and rebar?* Satisfactory Unsatisfactory Not Applicable Explain why*10. Water used when cutting concrete? (air born pathogens eliminated)* Satisfactory Unsatisfactory Not Applicable Explain why*11. Is there adequate signage, barrels, and cones?* Satisfactory Unsatisfactory Not Applicable Explain why*Housekeeping and Fall Prevention1. Work area neat and orderly?* Satisfactory Unsatisfactory Not Applicable Explain why*2. Trash picked up and put in proper places?* Satisfactory Unsatisfactory Not Applicable Explain why*3. Is the jobsite yard neatly organized in the best way to be productive?* Satisfactory Unsatisfactory Not Applicable Explain why*4. Tool trailer picked up and neatly organized?* Satisfactory Unsatisfactory Not Applicable Explain why*5. Are unattended manholes, catch basins, and potholed utilities protected? (cones, barrels or covered)* Satisfactory Unsatisfactory Not Applicable Explain why*6. Inactive excavation properly protected? (barricades or fence)* Satisfactory Unsatisfactory Not Applicable Explain why*7. Are the trucks cleaned and maintained?* Satisfactory Unsatisfactory Not Applicable Explain why*8. Is the equipment clean and maintained?* Satisfactory Unsatisfactory Not Applicable Explain why*9. Are the equipment and trucks properly parked?* Satisfactory Unsatisfactory Not Applicable Explain why*PPE1. Hard hats?* Satisfactory Unsatisfactory Not Applicable Explain why*2. Safety glasses?* Satisfactory Unsatisfactory Not Applicable Explain why*3. Gloves?* Satisfactory Unsatisfactory Not Applicable Explain why*4. Class 2 hi-visibility vest?* Satisfactory Unsatisfactory Not Applicable Explain why*5. Proper ear protection?* Satisfactory Unsatisfactory Not Applicable Explain why*6. Are dielectric boots being worn?* Satisfactory Unsatisfactory Not Applicable Explain why*7. Is there proper fall protection?* Satisfactory Unsatisfactory Not Applicable Explain why*Excavation1. Active locate ticket?* Satisfactory Unsatisfactory Not Applicable Explain why*2. Excavation log complete?* Satisfactory Unsatisfactory Not Applicable Explain why*3. Aware of overhead power lines (no closer then 10')* Satisfactory Unsatisfactory Not Applicable Explain why*4. Trench protection used over 5' deep?* Satisfactory Unsatisfactory Not Applicable Explain why*5. Trench box certification onsite?* Satisfactory Unsatisfactory Not Applicable Explain why*6. Trench box 2' from bottom of excavation?* Satisfactory Unsatisfactory Not Applicable Explain why*7. Trench box extends 18" over vertical sides of combination trench?* Satisfactory Unsatisfactory Not Applicable Explain why*8. Spoil 2' from trench edge?* Satisfactory Unsatisfactory Not Applicable Explain why*9. Ladder used over 4' deep?* Satisfactory Unsatisfactory Not Applicable Explain why*10. Ladder within 25' of employees?* Satisfactory Unsatisfactory Not Applicable Explain why*11. Is the trench box in good condition* Satisfactory Unsatisfactory Not Applicable Explain why*12. Are ladders being used properly?* Satisfactory Unsatisfactory Not Applicable Explain why*13. Are the excavator inspection forms complete?* Satisfactory Unsatisfactory Not Applicable Explain why*Heavy Equipment1. Are the backup and motion alarms working?* Satisfactory Unsatisfactory Not Applicable Explain why*2. Seat belts in use?* Satisfactory Unsatisfactory Not Applicable Explain why*3. Mirrors properly adjusted?* Satisfactory Unsatisfactory Not Applicable Explain why*Hand and Power Tools1. High pressure relief valve on air compressors?* Satisfactory Unsatisfactory Not Applicable Explain why*2. Tool handles in good condition?* Satisfactory Unsatisfactory Not Applicable Explain why*3. All power cords free from damage?* Satisfactory Unsatisfactory Not Applicable Explain why*4. Are employees trained for the tool they are using?* Satisfactory Unsatisfactory Not Applicable Explain why*5. Are all guards in place and properly working?* Satisfactory Unsatisfactory Not Applicable Explain why*6. GFCI being used?* Satisfactory Unsatisfactory Not Applicable Explain why*Material Handling and Rigging1. Rating tags on lifting chains?* Satisfactory Unsatisfactory Not Applicable Explain why*2. Rating labels legible on all lifting straps?* Satisfactory Unsatisfactory Not Applicable Explain why*3. Safety latches on hooks?* Satisfactory Unsatisfactory Not Applicable Explain why*4. Lifting equipment being used properly?* Satisfactory Unsatisfactory Not Applicable Explain why*5. All lifting equipment stored properly?* Satisfactory Unsatisfactory Not Applicable Explain why*I. Other Areas (Please Fill in As Necessary)II. Additional Comments (Please Fill in As Necessary)Send this report to:Select one or multiple people to receive this report:* A. Boyles B. Gentry C. Rader E. Hanson J. Morgan M. Huss O. Loza R. Martin S. Herrman T. Jones L. Weinberg J. Stroud
