Weekly Safety Form - HVAC, Inc.

Job Site Information

Job Site Name, City, State*

(Ex: VA Bldg 9, Asheville, NC)

Overall Site Description

Date

Inspected by:*

First Last

Are first aid supplies readily available?*

If not this must be corrected immediately, contact Safety Director ASAP 828-767-2183.

Are HVAC, Inc. work areas neat with materials and tools safely out of the way?*

Are there any sharp protruding points like sheet metal corners or nails in the work area?*

Are waste containers provided and being used?*

Are dust masks available for voluntary use?*

Are all HVAC, Inc. operations done in accordance with our Silica Exposure Plan?*

Are there adequate fire extinguishers in the work area?*

All welding sites MUST have a fire extinguisher.

Are the job boxes free of petroleum products and volatile chemicals?*

Have all HVC, Inc. extension cords been inspected for ground prong and knicks?*

Please inspect each cord for nicks and firm ground pin. If the cord is damaged discontinue from use immediately. Teach coworkers to do this when they lay-out and put-up the cord each time.

Are all power sources GFCI protected?*

Make sure all power sources are either a GFCI outlet or pigtail. Please remind employees to test the GFCI EVERY SINGLE TIME they plug-in.

Are extension cords out of stairwells and walkways?*

Make sure all extension cords are safely out of the way and never in a stairwell or walkway.

Have tools with a ground pin been inspected this week?*

Always make sure grounded tools have a firm ground pin in place. Never use a tool with a loose or missing ground pin.

Are the power tools in good condition and all moving parts properly guarded?*

Never try to repair or alter a power tool or machine.

Employees exposed to fall hazards are working in accordance with our PFAS plan*

Employees using a scissor lift have the proper harness and lanyard?*

Employees below protected from falling objects?*

Do extensions ladders onto another level extend 36" above the landing and are tied off?*

Ladders are secured to prevent slipping and the feet are in good condition?*

Ladders are inspected daily and removed service at any sign of damage or defect?*

Employees are not using the top two steps of a ladder?*

Please remind coworkers about this rule, ladders become very unstable if you are on the top two rungs.

How many HVAC, Inc. scaffolds are on the job site?*

All scaffolds are inspected daily?*

All penetrations greater than 2" are covered, secured, and marked?*

Any hole or penetration in the floor greater than 2" must be covered with a board and secured with 2x4 in the hole. The board must be marked "HOLE" in orange spray paint. This includes circular and square penetrations.

Leading edge perimeters are protected with proper barricade?*

Materials and tools are stored away from edges?*

Competent person on hand inspecting daily?*

Excavations over 5' in depth are shored or sloped back?*

Ladders every 25 feet when trench is more than 4 feet deep?*

Underground utilities have been located?*

Materials are properly and neatly stored or stacked out of the way?*

Gas cylinders stored upright and secured?*

Proper seperating barrier between fuels and oxygen?*

Ensure there is a 20 minutes barrier between fuel and oxygen tanks.

Welding goggles and proper PPE are being used?*

Fire extinguisher in area of welding?*

Welding screens are used properly?*

Hot work permit posted when required?*

Hard hats are being worn?*

Safety glasses are always worn while working?*

Dust masks are avaible to use voluntarily?*

Ensure dust masks for available for any employee who wants one.

Hearing protection is available for employees?*

High visibility outer layer worn when required?*

All employees have been trained on the Hazcom program and SDS?*

Ensure all employees know how to access the digital SDS on job site tablet or online.

What PPE is needed to cover the entire scope of work?

Check all that apply

Hard Hat
Safety Glasses
Face Sheild
Hearing Protection
Fall Protection
Welding Protection
High Visibility Outer Layer

Conclusion & Signature

Please be accurate and use the additional space for any notes, special considerations, and suggestions to improve the safety program.

Final Conclusion - Overall job site*

Based on your observations today, how would you rate the overall safety of the entire job site including other contractors?

Final Conclusion - HVAC, Inc. operations*

Based on your observations today, how would you rate the safety of HVAC, Inc.'s work and safety awareness?

*Please explain if anything other than excellent

*Additional Notes

Optional - Notes for safety program improvement

Use this space to provide any suggestions that could improve the HVAC, Inc. safety program.

Signature*

Sign your initials here with your finger to acknowledge that you have completed this form to the best of your ability and that the job site is either totally safe, proper corrective actions have been taken, or the safety director has been contacted.

Safety Inspection Checklist

Job Site Information

Conclusion & Signature