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Self Assessment

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Safety and health audit form

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Self Assessment

  1. 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. 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. 3. OBSERVATION RESP. IND. CORRECTED
  4. 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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