1. Supplied by employer Yes No Not Needed DK
2. Worn when required Yes No DK
1. Supplied by workers Yes No Not Needed DK
2. Worn when required Yes No DK
1. Supplied by employer Yes No Not Needed DK
2. Worn when required Yes No DK
1. Supplied by employer Yes No Not Needed DK
2. Worn when required Yes No DK
1. Supplied by employer Yes No Not Needed DK
2. Training provided Yes No DK
3. Worn when required Yes No DK
1. Correct size for the job Yes No DK
2. Fully opened and spreader bars locked Yes No DK
3. Firm foundation for ladder feet Yes No DK
4. Proper climbing procedures Yes No DK
5. Three-point contact rule followed Yes No DK
6. Free from obvious defects Yes No DK
7. Workers stand below top 2 steps Yes No DK
8. Extend more than three feet above support Yes No DK
Scaffolds: Are present at this worksite? Yes No Do not know
1. Fall protection used if over 10 feet tall Yes No DK
2. Set up on level, stable footing Yes No DK
3. Platform is appropriate width for type of scaffold Yes No DK
Fall Protection: Needed at this worksite? Yes No Do not know
1. Fall protection provided for heights 6 ft. or more Yes No DK
2. Harness is worn properly and attached to Yes No DK
secure anchorage
3. Slide guards are installed across full width and all sides Yes No DK
4. Guardrails set up for openings >6’ above lower level Yes No DK
5. Guardrails are constructed sturdily with 2 x 4s Yes No DK
Machine Hazards: Are power tools and machines used at this site? Yes No Do not know
1. Workers are trained on the use of power tools. Yes No DK
2. Workers have appropriate PPE and keep clothing away Yes No DK
3. Workers are trained prior to using nail guns Yes No DK
4. Tile and concrete are cut with wet methods Yes No DK
Heat Stress: Is heat a major problem at this site? Yes No Do not know
1. Have workers been trained on preventing and Yes No DK
recognizing heat-related illness?
2. Are workers provided with enough water and Yes No DK
appropriate rest breaks?
Lead Paint Hazards: Is the site at risk for lead-contaminated dust? Yes No Do not know
1. Have workers been trained on handling lead dust? Yes No DK
2. Is the work area properly contained? Yes No DK
Electrical Hazards: Are present at this worksite? Yes No Do not know
1. Work on electrical circuits or energized equipment Yes No DK
is begun only after all power sources have been
identified, de-energized and locked out or tagged out.
2. Overhead and underground electrical power lines Yes No DK
are located, identified, and avoided.
3. Ladders, scaffolds, equipment or materials more Yes No DK
than 10 feet from any electrical power lines
Excavations: Are present at this worksite? Yes No Do not know
1. Soil and conditions are inspected everyday Yes No DK
2. Safe exits (ladders) for excavations greater Yes No DK
than 4 ft. deep
3. Shoring, shielding, and inclination assessed Yes No DK
for excavations greater than 5 ft. deep