SURFACE WORKPLACE AUDIT FORM

LOCATION:

/

TASK:

/

DATE:

PERSONAL PROTECTIVE EQUIPMENT

AUDITED ITEM / Yes / No / N/A / AUDITED ITEM / Yes / No / N/A
Boots (good condition with Met Guards) / Gloves (proper for task being done)
Eye Protection (i.e. Glasses) /

Respirator Protection Proper

Face Shield / Clean Shaven (Respirator fit)
Goggles / Task Specific PPE Worn
Hearing Protection / Proper Fall Protection
Double Hearing Protection / Travel Restraint (lanyard length)
Hard Hat (Good Condition, Reflective Material to Standard, Worn properly) / Reflective Striping
(Standard & in good condition)
Immediate Actions Taken to Reduce Risk to ALARA: /

Action By:

HOUSEKEEPING

AUDITED ITEM / Yes / No / N/A / AUDITED ITEM / Yes / No / N/A
Workspace clear of tripping hazards / Lighting Adequate
Garbage removed or neatly piled for removal. / Services supported properly
(air, water, electrical cables)

Area addressed for dust control

(i.e. watered down, vacuumed) / Materials, tools & equipment stored properly
Slippery Conditions (mud, slimes, ice, etc.) /

Travel ways free from obstructions

Clearance for Electrical Installations /

Process Leaks (Liquid, Solid, Gas)

Immediate Actions Taken to Reduce Risk to ALARA: /

Action By:

HAZARD IDENTIFICATION

AUDITED ITEM / Yes / No / N/A / AUDITED ITEM / Yes / No / N/A
Open Holes Identified & Secured
(i.e. guardrails and signs proper) / Area secured from inadvertent access or guarded properly
(i.e. welding curtains in place)
Machine Guards in place / Suspended Load Area Secured
Moving equipment hazards addressed / Fire Precautions Taken
Burning equipment properly located, guarded & secured / Energy Sourced Isolated
(i.e. mechanical, elect, gravity, etc)
Immediate Actions Taken to Reduce Risk to ALARA: /

Action By:

ISOLATION

AUDITED ITEM / Yes / No / N/A / AUDITED ITEM / Yes / No / N/A
Personal Protection Tags / Managers Tag (i.e. valid, completed)
Equipment Status Tags / All Energy Sources
Locked Out & Tested
Immediate Actions Taken to Reduce Risk to ALARA: /

Action By:

CONFINED SPACE

AUDITED ITEM / Yes / No / N/A / AUDITED ITEM / Yes / No / N/A

Permit Completed Correctly

/ Rescue Equipment at Site
Identified in the Field (permanent signs) / Rescue Plan Reviewed & Signed
Entry Plan Available / Rescuers Familiar with Equip.
Plan Reviewed with all Team Members / Personnel signed in / out
Rescue Plan Effective / Attendant Identified
Rescuers Readily Available / Fall Arrest Required
Immediate Actions Taken to Reduce Risk to ALARA: /

Action By:

EMERGENCY PROTECTION

AUDITED ITEM / Yes / No / N/A
Eye Wash Station
Fire Extinguisher(s)
Stretcher(s)
First Aid Kit
Actions Taken to Reduce Risk to ALARA: /

Action By:

MOBILE EQUIPMENT

AUDITED ITEM / Yes / No / N/A
Seat Belt Worn
Pre-op Inspection Completed
Actions Taken to Reduce Risk to ALARA: /

Action By:

CONTRACTOR

AUDITED ITEM / Yes / No / N/A
NORCAT
Site Specific Orientation
Emergency Procedures Understood
ZES Certified
Standards Observed at Jobsite

Signed In (if required)

Actions Taken to Reduce Risk to ALARA: /

Action By:

GENERAL COMMENTS:

AUDITED BY:

FORM # STA-0700 PAGE 2 OF 2