Worksite Safety Inspection

Location / Project #

Date / Time

Date

Time

Site Foreman

Inspector Name

Site Crew

Personal Protective Equipment

Eye Protection - Safety Glasses (Mandatory at all Times) *

• Yes
• No
• N/A

Violations - Issue, Corrective Action Required, Names

Hand Protection - Gloves, Proper Usage *

• Yes
• No
• N/A

Violations - Issue, Corrective Action Required, Names

Foot Protection-Approved Steel, Comp Toe (Mandatory) *

• Yes
• No
• N/A

Violations - Issue, Corrective Action Required, Names

Hearing Protection-Plugs, Earmuffs (Site / Task Specific) *

• Yes
• No
• N/A

Violations - Issue, Corrective Action Required, Names

Head Protection - Hard Hats (Site / Task Specific) *

• Yes
• No
• N/A

Violations - Issue, Corrective Action Required, Names

Safety Apparel - Hi-Vis Class 2, 3 (Site / Task Specific) *

• Yes
• No
• N/A

Violations - Issue, Corrective Action Required, Names

RPE - Dust Mask, Respirator (Site / Task Specific) *

• Yes
• No
• N/A

Violations - Issue, Corrective Action Required, Names

Fall Protection - Harness, Lanyard (Site / Task Specific) *

• Yes
• No
• N/A

Violations - Issue, Corrective Action Required, Names

General Site Safety

Safety Cones - (Mandatory On All Occupied Worksites) *

• Yes
• No
• N/A

Violations - Issue, Corrective Action Required, Names

Signs / Barricades - (Site / Task Specific) *

• Yes
• No
• N/A

Violations - Issue, Corrective Action Required, Names

Ladder Safety - Free of Defects, Proper Usage *

• Yes
• No
• N/A

Violations - Issue, Corrective Action Required, Names

Electrical Cords - No Damage / Frayed Cord *

• Yes
• No
• N/A

Violations - Issue, Corrective Action Required, Names

GFCI In Use - Proper Usage / No Damage / Tested *

• Yes
• No
• N/A

Violations - Issue, Corrective Action Required, Names

Power Tools - Clean, Functional, Guards In Place *

• Yes
• No
• N/A

Violations - Issue, Corrective Action Required, Names

Hammer Drills - Dust Retractions System Engaged *

• Yes
• No
• N/A

Violations - Issue, Corrective Action Required, Names

General Housekeeping - Neat and Orderly Worksite *

• Yes
• No
• N/A

Violations - Issue, Corrective Action Required, Names

Competent Person On Site *

• Yes
• No
• N/A

Violations - Issue, Corrective Action Required, Names

Fire Extinguisher - ASM Vehicle (On Worksite If Required) *

• Yes
• No
• N/A

Violations - Issue, Corrective Action Required, Names

Van Inspection (Does Not Affect Safety Score)

Company Van - Clean / Organized *

• Yes
• No
• N/A

Violations - Issue, Corrective Action Required, Names

First Aid Kit *

• Yes
• No
• N/A

Violations - Issue, Corrective Action Required, Names

Van Checklist - Complete and Up to Date *

• Yes
• No
• N/A

Violations - Issue, Corrective Action Required, Names

Van Maintenance Up To Date - (Window Sticker) *

• Yes
• No
• N/A

Violations - Issue, Corrective Action Required, Names (copy)

Total Violations:

Score Review

• 0=PASS
• 1=WARNING
• 2+=FAIL

Inspection Comments

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