Construction Safety Assessment
Date
dd/mm/yyyy
Date
-
Month
-
Day
Year
Date
Type of Assessment
Scheduled Safety Assessment
Walk Through
Status
Initial
In Progress
Closed
Division: Mark all that apply
JMAC
IHD Liquids Management
IHD Solids
WDW
Construction
Trucking
Shop
Materials
East Trucking
Ft. Berthold & Trucking
South Texas
West Texas
New Mexico
Williston
PNW
Client
Job/ Location
Current Activity
Supervisor on Duty
First Name
Last Name
Supervisor Email
Confirmation Email
Person Performing Assessment
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Assessor Email
example@example.com
Section 1: General Site Safety
1. Job Safety Analysis (JSA’s) not conducted
2. Parking area not in proper order
3. Lay down area/s and storage yard/s not in proper order
4. Wildlife presents an elevated risk
5. Unnecessary trip hazards present
6. Site security not in proper order
7. Material liquid and bulk storage not in proper order
8. Smoking occurring in restricted area/s
9. Cigarette butts not disposed of properly
10. Lifting equipment not in proper order
11. Haul trailer decking not in proper order
12. Restrooms not available or not in proper order
13. Safety Data Sheets (SDS) not available for chemicals in use
14. Labeling or signage not in proper order
15. Trash present outside of containment
16. Overhead and/or underground utilities not in proper order
17. 811 locate not in proper order
18. Trenching/ excavations not in proper order
19. Trenching competent person not in proper order
20. Drinking water not available
21. Electrical or grounding not in proper order
22. Flammable liquid storage not in proper order
23. Workers observed at height without proper fall protection
24. Stairways, walkways, toe-boards, guardrails and ladders not in proper order
25. Walking and working surface not in proper order
26. Spills present on location
27. Traffic control not in proper order
28. Confined space work not in proper order
29. Spill kits not in proper order
30. First aid supplies not in proper order
31. Various safety meetings are not conducted as required
32. Crew members have not attended JMAC &/or Client Safety Orientation
33. PPE not in proper order
34. Visitor tracking system not in proper order
35. Personal gas monitors not in use where required
36. Worker training not in proper order
37. Housekeeping not in proper order
38. Other
39. Section 1 "General Site Safety" no items of non-compliance discovered!
Number of Deficiencies in This Section
Note the count for the total number of deficiencies for this section (this includes multiples of like violations)
Notes:
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Section 2: Tool Storage, Power and Hand Tools
1. Tool storage trailer not in proper order
2. Power cords and hoses not in proper order
3. Fall protection not in proper order
4. Power Tools not in proper order
5. Hand tools not in proper order
6. Electrical not in proper order
7. Walking and working surface not in proper order
8. Housekeeping not in proper order
9. Other
10. Section 2 "Tool Storage, Power and Hand Tools" no items of non-compliance discovered!
Number of Deficiencies in This Section
Note the count for the total number of deficiencies for this section (this includes multiples of like violations)
Notes:
Photos Section 2
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Section 3: Hot Work & Fire Protection
1. Fire extinguishers not in proper order
2. Welding and cutting areas not in proper order
3. Housekeeping not in proper order
4. Hot Work Permit not in proper order
5. Welding equipment not in proper order
6. Acetylene and oxygen cylinders not in proper order
7. Fire watch not present
8. Other
9. Section 3 "Hot Work & Fire Protection" no items of non-compliance discovered!
Number of Deficiencies in This Section
Note the count for the total number of deficiencies for this section (this includes multiples of like violations)
Notes:
Photos Section 3
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Section 4: Powered Equipment
1. Equipment operating condition not in proper order
2. Equipment inspections not in proper order
3. Slings, chokers, and safety latches on hooks not in proper order
4. Seat belts or seat belt use not in proper order
5. Equipment shows to be leaking fluid
6. Spotter not present when required
7. Cab condition not in proper order
8. Butter Bar With Rounded Edges not present (If Required)
9. Equipment not adequately secured
10. Operator certification not in proper order as required
11. Other
12. Section 4 "Powered Equipment" no items of non-compliance discovered!
Number of Deficiencies in This Section
Note the count for the total number of deficiencies for this section (this includes multiples of like violations)
Notes:
Photos Section 4
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