Safety and health audit form

1. Company Name and Location
Internal Safety Self Assessment Program
The following is to be used as a guide by the team to perform the safety inspection. Observations should be
noted on the attached observation sheet. Upon completion of the inspection each category should be rated
as: 3 Excellent, 2 Good, 1 Fair, 0 Lacking or N/A Not Applicable.
Supervisor's Name: Date: Score Points %
Location: Safety Rep.: 0.00% Awarded
1 Housekeeping
1 Project work areas are clean and free of excess trash, debris 5
2 Walkways and passageways clear 5
3 Material or equipment properly stored 5
4 Electrical cords, hoses, welding leads, etc. elevated to prevent trip hazards 5
5 Scrap materiel free of protruding nails or other puncture hazards 5
6 Trash receptacles are provided for work areas and water kegs 5
7 Barricades, and/or rebar caps installed and maintained 5
8 Barricade tape & tags 5
POSSIBLE POINTS AWARDED 40 0 0%
2 Personal Protective Equipment
1 Hard hats worn and maintained as required 5
2 Hearing protection worn as required 5
3 Eye protection required and worn in a proper manner 5
4 Proper foot protection worn for job performed 5
5 Face shield or goggles worn as required 5
6 Other; respirators, gloves, chemical resistant garments 5
POSSIBLE POINTS AWARDED 30 0 0%
3 Fall Protection
1 Body harness required and worn in a proper manner 5
2 Lanyards are adequately secured to suitable anchorage 5
3 Perimeter guarding 5
4 Static lines, rat lines installed and capable of supporting 5,400 lbs. of force 5
5 Fall protection equipment is used only for fall protection 5
6 Fall protection maintained and has current inspection 5
POSSIBLE POINTS AWARDED 30 0 0%
4 Excavations
1 Sloped and shored properly 5
2 Access and egress provided every 25 ft. 5
3 Daily documented inspections conducted 5
POSSIBLE POINTS AWARDED 15 0 0%
5 Scaffolds and Ladders
1 Built per specification and inspected 5
2 Proper access and egress provided 5
3 Tagged correctly 5
4 Proper ladder for the job performed / properly secured 5
5 Proper angle and exceed the landing 3 ft. 5
POSSIBLE POINTS AWARDED 25 0 0%

2. Company Name and Location
Internal Safety Assessment Report (Page 2)
6 Hoisting and Lifting Equipment Score See Points
1 Chainfalls, come-a-longs and chokers in good condition with current inspection 5
2 Softeners used as required 5
3 Proper rigging techniques used 5
POSSIBLE POINTS AWARDED 15 0 0%
7 Vehicles / Mobil Equipment
1 Lights, brakes, horns, alarms working properly 5
2 Seat belts provided and used 5
3 Properly maintained 5
4 Equipment used properly 5
5 Licenses or certifications as required 5
POSSIBLE POINTS AWARDED 25 0 0%
8 Tools and Equipment
1 Electrical cords - condition and current inspection 5
2 Tools are maintained in a safe condition 5
3 Tools are properly carried and stored 5
4 Pneumatic / hydraulic hose connections properly secured 5
5 Proper tools used for the job performed 5
6 Portable Generators 5
POSSIBLE POINTS AWARDED 30 0 0%
9 Fire Protection
1 Flammables stored properly 5
2 Oxygen and combustibles separated 5
3 Containers labeled as to content 5
4 Fire extinguishers properly located and inspected 5
5 Flash arrestors installed 5
6 Compressed gas cylinders properly maintained 5
7 Containment of hot work and welding screens as required 5
8 Regulator gauges properly attached and maintained 5
POSSIBLE POINTS AWARDED 40 0 0%
10 Permits / Safety Task Permits
1 Applicable permits posted 5
2 Pre-talk-safety reviews (STA's) 5
3 Procedures being followed i.e., Hazard assessment, confined space, lead, 5
asbestos etc.
POSSIBLE POINTS AWARDED 15 0 0%
POINTS SCORED 265 0
ADJUSTED SCORE 0.00%
11 Signatures Required; Supervisor-
General Foreman-
Superintendent-
Safety Rep.-

3. OBSERVATION RESP. IND. CORRECTED

4. Company Name and Location
Internal Safety Assessment Summary
The following is the rating classification established for the program;
95 to 100 Excellent 90 to 94 Good
85 to 89 Fair 70 to 84 Lacking
NOTE: This is the first documented inspection for this project
Supervisor's Name: Date: Score
Location: Safety Rep.: 0.00%
1 Housekeeping 40 0 0%
2 Personal Protective Equipment 30 0 0%
3 Fall Protection 30 0 0%
4 Excavations 15 0 0%
5 Scaffolds and Ladders 25 0 0%
6 Hoisting and Lifting Equipment 15 0 0%
7 Vehicles / Mobil Equipment 25 0 0%
8 Tools and Equipment 30 0 0%
9 Fire Protection 40 0 0%
10 Permits / Safety Task Assignment 15 0 0%

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8. B
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