Work Site Safety Inspection
Date of Inspection
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Work Site
*
224 Muskrat Street
208 Otter Street
Enter Site if not listed above
# of Workers on Site
*
Site Superintendent (Old)
*
Please Select
Louise Green
Sandra Fleming
Site Supervisor 1
Site Superintendent
*
Site Superintendent Email
*
example@example.com
Manager
*
Manager Email
*
example@example.com
Contractors/Workers On Site
Scope of Work
Site Work
Cribbing
Framing
Siding
Roofing
Dry Walling
Carpentry
Steel Framing
Concrete
Painting
Plumbing
Masonry
Add Other Scope of Work
Describe Specific Scope of Work
Weather
Sunny
Overcast
Rain
Snow
Windy
Other
Temperature °C
Was a toolbox talk completed?
Yes
No
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Inspection Items and Corrective Actions
Have there been any near misses?
YES
NO
Please explain
Are there any outstanding items form the last inspection?
YES
NO
Items Outstanding
Certificates/Tickets (copy on site)
Please Select
Imminent Danger
Serious
Minor
Acceptable
N/A
Certificates/Tickets (copy on site) Comments / Corrective Actions
Responsible
Target Date
-
Month
-
Day
Year
Who Corrected
Date Corrected
-
Month
-
Day
Year
Chemical Storage
Please Select
Imminent Danger
Serious
Minor
Acceptable
N/A
Chemical Storage Comments / Corrective Actions
Responsible
Target Date
-
Month
-
Day
Year
Who Corrected
Date Corrected
-
Month
-
Day
Year
Electrical
Please Select
Imminent Danger
Serious
Minor
Acceptable
N/A
Electrical Comments / Corrective Actions
Responsible
Target Date
-
Month
-
Day
Year
Who Corrected
Date Corrected
-
Month
-
Day
Year
Equipment Inspections
Please Select
Imminent Danger
Serious
Minor
Acceptable
N/A
Equipment Inspections Comments / Corrective Actions
Responsible
Target Date
-
Month
-
Day
Year
Who Corrected
Date Corrected
-
Month
-
Day
Year
ERP
Please Select
Imminent Danger
Serious
Minor
Acceptable
N/A
ERP Comments / Corrective Actions
Responsible
Target Date
-
Month
-
Day
Year
Who Corrected
Date Corrected
-
Month
-
Day
Year
Excavations
Please Select
Imminent Danger
Serious
Minor
Acceptable
N/A
Excavations Comments / Corrective Actions
Responsible
Target Date
-
Month
-
Day
Year
Who Corrected
Date Corrected
-
Month
-
Day
Year
Fire Extinguishers
Please Select
Imminent Danger
Serious
Minor
Acceptable
N/A
Fire Extinguishers Comments / Corrective Actions
Responsible
Target Date
-
Month
-
Day
Year
Who Corrected
Date Corrected
-
Month
-
Day
Year
First Aid Kits/First Aid
Please Select
Imminent Danger
Serious
Minor
Acceptable
N/A
First Aid Kits/First Aid Comments / Corrective Actions
Responsible
Target Date
-
Month
-
Day
Year
Who Corrected
Date Corrected
-
Month
-
Day
Year
Fall Protection/Fall Arrest
Please Select
Imminent Danger
Serious
Minor
Acceptable
N/A
Fall Protection/Fall Arrest Comments / Corrective Actions
Responsible
Target Date
-
Month
-
Day
Year
Who Corrected
Date Corrected
-
Month
-
Day
Year
Fall Protection Barricades
Please Select
Imminent Danger
Serious
Minor
Acceptable
N/A
Fall Protection Barricades Comments / Corrective Actions
Responsible
Target Date
-
Month
-
Day
Year
Who Corrected
Date Corrected
-
Month
-
Day
Year
Fall Protection Plan (if required)
Please Select
Imminent Danger
Serious
Minor
Acceptable
N/A
Fall Protection (if required) Comments / Corrective Actions
Responsible
Target Date
-
Month
-
Day
Year
Who Corrected
Date Corrected
-
Month
-
Day
Year
Hazard Assessments reviewed
Please Select
Imminent Danger
Serious
Minor
Acceptable
N/A
Hazard Assessments reviewed Comments / Corrective Actions
Responsible
Target Date
-
Month
-
Day
Year
Who Corrected
Date Corrected
-
Month
-
Day
Year
Health & Safety Committee
Please Select
Imminent Danger
Serious
Minor
Acceptable
N/A
Health & Safety Committee Comments / Corrective Actions
Responsible
Target Date
-
Month
-
Day
Year
Who Corrected
Date Corrected
-
Month
-
Day
Year
Hot Work Permit
Please Select
Imminent Danger
Serious
Minor
Acceptable
N/A
Hot Work Permit Comments / Corrective Actions
Responsible
Target Date
-
Month
-
Day
Year
Who Corrected
Date Corrected
-
Month
-
Day
Year
Housekeeping
Please Select
Imminent Danger
Serious
Minor
Acceptable
N/A
Housekeeping Comments / Corrective Actions
Responsible
Target Date
-
Month
-
Day
Year
Who Corrected
Date Corrected
-
Month
-
Day
Year
Ladders
Please Select
Imminent Danger
Serious
Minor
Acceptable
N/A
Ladders Comments / Corrective Actions
Responsible
Target Date
-
Month
-
Day
Year
Who Corrected
Date Corrected
-
Month
-
Day
Year
Lighting
Please Select
Imminent Danger
Serious
Minor
Acceptable
N/A
Lighting Comments / Corrective Actions
Responsible
Target Date
-
Month
-
Day
Year
Who Corrected
Date Corrected
-
Month
-
Day
Year
Material Storage
Please Select
Imminent Danger
Serious
Minor
Acceptable
N/A
Material Storage Comments / Corrective Actions
Responsible
Target Date
-
Month
-
Day
Year
Who Corrected
Date Corrected
-
Month
-
Day
Year
Orientations Completed
Please Select
Imminent Danger
Serious
Minor
Acceptable
N/A
Orientations Completed Comments / Corrective Actions
Responsible
Target Date
-
Month
-
Day
Year
Who Corrected
Date Corrected
-
Month
-
Day
Year
PPE (Specified Below)
Please Select
Imminent Danger
Serious
Minor
Acceptable
N/A
PPE Comments / Corrective Actions
Responsible
Target Date
-
Month
-
Day
Year
Who Corrected
Date Corrected
-
Month
-
Day
Year
Protection of the Public
Please Select
Imminent Danger
Serious
Minor
Acceptable
N/A
Protection of the Public Comments / Corrective Actions
Responsible
Target Date
-
Month
-
Day
Year
Who Corrected
Date Corrected
-
Month
-
Day
Year
Safety Meeting/Toolbox Records
Please Select
Imminent Danger
Serious
Minor
Acceptable
N/A
Safety Meeting/Toolbox Records Comments / Corrective Actions
Responsible
Target Date
-
Month
-
Day
Year
Who Corrected
Date Corrected
-
Month
-
Day
Year
Scaffolding
Please Select
Imminent Danger
Serious
Minor
Acceptable
N/A
Scaffolding Records Comments / Corrective Actions
Responsible
Target Date
-
Month
-
Day
Year
Who Corrected
Date Corrected
-
Month
-
Day
Year
Signage
Please Select
Imminent Danger
Serious
Minor
Acceptable
N/A
Signage Records Comments / Corrective Actions
Responsible
Target Date
-
Month
-
Day
Year
Who Corrected
Date Corrected
-
Month
-
Day
Year
Site Conditions
Please Select
Imminent Danger
Serious
Minor
Acceptable
N/A
Site Conditions Records Comments / Corrective Actions
Responsible
Target Date
-
Month
-
Day
Year
Who Corrected
Date Corrected
-
Month
-
Day
Year
Tools
Please Select
Imminent Danger
Serious
Minor
Acceptable
N/A
Tools Records Comments / Corrective Actions
Responsible
Target Date
-
Month
-
Day
Year
Who Corrected
Date Corrected
-
Month
-
Day
Year
Other Hazard
Please Select
Imminent Danger
Serious
Minor
Acceptable
N/A
not listed above
Other Hazards Records Comments / Corrective Actions
Responsible
Target Date
-
Month
-
Day
Year
Who Corrected
Date Corrected
-
Month
-
Day
Year
Safety Summary
Inspection Photographs
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Corrective Action Photographs
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Inspector Name
*
Inspector Email
*
example@example.com
Inspection Team
Inspector Signature
*
Has the form been QC'd and ready to send to the client?
*
YES
NO
Work Site Superintendent Name
Work Site Superintendent Date Signed
-
Month
-
Day
Year
Date
Work Site Superintendent Signature
Manager Name
Manager Date Signed
-
Month
-
Day
Year
Date
Manager Signature
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