Job_Site_Checklist 91019

Job Site Checklist - General
Job Site Identification:
Job Site Identification:
Date:
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature of Competent Person
Clear
Check appropriate box:
Rows YesNoNA - -
a.OSHA Form 3165 1 2 3
b.OSHA Form 300A (February 1 to April 30) 4 5 6
c.Emergency Phone Numbers Hospital - Emergency Response - Main Office 7 8 9

Rows	YesNoNA	-	-
a.OSHA Form 3165	1	2	3
b.OSHA Form 300A (February 1 to April 30)	4	5	6
c.Emergency Phone Numbers Hospital - Emergency Response - Main Office	7	8	9

accessible and current

Rows	-	-	-
a.MSDS or SDS readily accessible	10	11	12
b.Hazard communication information “shared	13	14	15
c.Fire extinguishers accessible and inspected	16	17	18
d.Record Keeping: JHA’s and job site forms readily	19	20	21

accessible and current
Rows - - -
e.Employees appropriately trained 22 23 24
f.Signage & DOT labels and placards in place 25 26 27

Rows	-	-	-
e.Employees appropriately trained	22	23	24
f.Signage & DOT labels and placards in place	25	26	27

Job Site

Rows	-	-	-
a.First aid kits available and stocked	28	29	30
b.General housekeeping – area free from debris	31	32	33
c.Compactor/trash Disposal procedures in place	34	35	36
d.Storage areas maintained in orderly manner	37	38	39
c.Adequate restrooms facilities	40	41	42
e.Potable water available	43	44	45
f.Warning signs, tags, barricade tape in place	46	47	48
g.Walking/Working Surfaces	49	50	51

Temporary Electrical Wiring

Rows	-	-	-
a.Extension cords inspected & free of defects	52	53	54
b.Ground fault circuit interrupters (GFCI) in use	55	56	57
c.All equipment properly grounded	58	59	60
d.Temporary wiring clear of employee & vehicular traffic	61	62	63

Job Site Checklist - General 1 of 3
© 2014 U.S. Compliance Systems, Inc. (888) 475-5353. Permission is granted to copy for internal use.

Ergonomics

Rows	Yes No NA	-	-
a.Proper lifting techniques being employed	64	65	66
a.Hard Hats	67	68	69
b.Eye protection	70	71	72
c.Appropriate, approved, work shoes	73	74	75
d.Hearing protection	76	77	78
e.Gloves	79	80	81
f.Respiratory Protection	82	83	84
a.Adequate lighting	85	86	87
b.Medical Services reasonable accessible	88	89	90
c.Administrative and/or Engineering Controls in place to	91	92	93
d.Protection from ionizing and/or nonionizing radiation	94	95	96
e.Emergency Action Plan and Fire Prevention	97	98	99

Personal Protective Equipment (PPE) Required
Note: Serviceable equipment available & training received
Equipment including PPE, Ladders, Scaffolds & Tools
Rows - - -
a.Inspected before use 100 101 102
b.Defective items tagged and removed from service 103 104 105
c.Powered Equipment operators trained and authorized 106 107 108
Ladders
Rows - - -
a.Side rails extend at least 3’ above upper landing surface 109 110 111
b.Ladders tied-off to prevent displacement 112 113 114
Scaffolds
Rows - - -
a.Guard rails 115 116 117
b.Full planking 118 119 120
c.Bracing 121 122 123
d.Ladder access 124 125 126
e.Toe boards 127 128 129
Job Site Checklist - General 2 of 3
© 2014 U.S. Compliance Systems, Inc. (888) 475-5353. Permission is granted to copy for internal use.
competent to recognize fall hazards & know the responsibilities of the position.
is on site.

Rows	-	-	-
a.Inspected before use	100	101	102
b.Defective items tagged and removed from service	103	104	105
c.Powered Equipment operators trained and authorized	106	107	108

Rows	-	-	-
a.Side rails extend at least 3’ above upper landing surface	109	110	111
b.Ladders tied-off to prevent displacement	112	113	114

Rows	-	-	-
a.Guard rails	115	116	117
b.Full planking	118	119	120
c.Bracing	121	122	123
d.Ladder access	124	125	126
e.Toe boards	127	128	129

Other

Rows	Yes No NA	-	-
a.Personnel trained in fall protection	130	131	132
b.Conventional Fall Protection System Used	133	134	135
1.Guardrail System	136	137	138
2.Personal Fall Arrest System	139	140	141
3.Warning Line System	142	143	144
4.Controlled Access Zone System	145	146	147
5.Safety Monitoring System: Monitor must be	148	149	150
d.Fall Protection Plan used: 29 CFR 1926.502(k);	151	152	153
a.Employees demonstrating a positive safety attitude	154	155	156
a.	157	158	159
b.	160	161	162
c.	163	164	165
d.	166	167	168
e.	169	170	171
f.	172	173	174

a.
b.
c.
d.
e.
f.
Unsafe work practices will be corrected immediately upon discovery and if total job site safety cannot be restored, job will be shut down until corrections are made. The below listed persons were working in an unsafe manner & enforcement documentation is or will be prepared at the earliest opportunity consistent with safety.
Unsafe Act & Corrective Measure:
Job Site Checklist - General 3 of 3
© 2014 U.S. Compliance Systems, Inc. (888) 475-5353. Permission is granted to copy for internal use.
Certificate of Job Site Hazard Assessment
I certify, this date, that I have performed a hazard assessment of our job sites and our methods of operations. This hazard assessment was accomplished to determine if hazards are present, or are likely to be present, which necessitate the use of personal protective equipment PPE Identified hazards which cannot be eliminated through engineering controls or changes in procedures will be addressed by the use of selected PPE. All affected employees will be informed of the required PPE for specific work locations or specific types of work to be performed and will receive initial training or retraining, if necessary, before being allowed to perform work requiring PPE. If conditions or procedures change, a reassessment will be made.
Clear
Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Personal Protective Equipment Program Administrator
Certificate of Job Site Hazard Assessment 1 of 1
© 2014 U.S. Compliance Systems, Inc. (888) 475-5353. Permission is granted to copy for internal use.
Should be Empty: