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Address
Date / Time
Date
Time
Site Conditions
File Upload
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PPE Mandatory
High Visbility Vest
Hard Hat
Steel Toes
Main Floor
Open Excavation
Yes
No
If yes state control
Barricade (guard rails/ temp fence)
Use Caution Stay Clear
Snow/Ice
Yes
No
If yes state control
Salt/Shovel
Weather delay
Open Stairwell
Yes
No
If yes state control
Barricade
Other
Cords Good Working Condition?
Yes
No
If no state control
Repair
Replace
Ladders in Good Working Condition?
Yes
No
If no state control
Repair
Replace
Heavy Machinery
Yes
No
PPE
Yes
No
Second Floor
Windows/Exterior Perimeter Hazard
Yes
No
If yes state control
Guard rails
Scaffold
Open stairwell
Yes
No
If yes state control
Barricade
Other
Snow/Ice
Yes
No
If no state control
Salt/Shovel
Weather delay
Cords Good Working Condition?
Yes
No
If no state control
Repair
Replace
Ladders in Good Working Condition?
Yes
No
If no state control
Repair
Replace
Heavy Machinery
Yes
No
PPE
Yes
No
Roof
Windows/Exterior Perimeter Hazard
Yes
No
If yes state control
Ropes/Harnesses
Toeboards/Anchorpoints
Snow/Ice
Yes
No
If no state control
Salt/Shovel
Weather delay
Cords Good Working Condition?
Yes
No
If no state control
Repair
Replace
Ladders in Good Working Condition?
Yes
No
If no state control
Repair
Replace
Heavy Machinery
Yes
No
PPE
Yes
No
Fall Potential
Yes
No
Fall Arrest
Yes
No
Additional Information (Action Taken )
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