safety checklist and forms

Safety Checklist and Forms

2017 Edition

P . O B o x 3 3 9

G i g H a r b o r , W A 9 8 3 3 5

O f f i c e ( 2 5 3 ) 8 5 3 - 2 3 0 4

F a x ( 2 5 3 ) 8 5 3 - 5 9 2 1

w w w . w a p a t r i o t . c o m

TABLE OF CONTENTS- CHECKLISTS & FORMS

LEAD │ DESIGN │ CONSTRUCT │ SERVE

Section Title Revision

Date Revision #

2 SITE GENERAL – CHECKLISTS & FORMS

2-A Employee Safety Orientation Checklist/Ladder Safety 9/26/13 1

2-B Daily Safety Audit Checklist 9/26/13 1

2-C Stretch & Flex Program Sign-In 9/26/13 1

2-D Weekly Site Safety Checklist 9/26/13 1

2-E Safety Meeting 9/26/13 1

2-F Pre-Task Plan Checklist 1/30/17 1

2-G Safety Meeting – Sample 1/30/17 1

3 PERSONAL PROTECTION

3-A Medical Evaluation Questionnaire for Respirator Users 9/26/13 1

3-B Confined Space Entry Permit 9/26/13 1

3-C Employee Fall Arrest and Restraint Training 9/26/13 1

3-D Fall Protection Work Plan 9/26/13 1

4 TOOLS, EQUIPMENT & SITE SAFETY

4-A Crane and Hoist Safety 9/26/13 1

4-B Crane Checklist 9/26/13 1

4-C Elevated Work Platform 9/26/13 1

4-D Daily Inspections Checklist for All Driven Equip 3/15/16 1

4-E Equipment Operator Training 9/26/13 1

4-F Company Vehicle Accident Report 9/26/13 1

4-G One Ton Inspection 9/26/13 1

4-H Daily Scaffold Inspection 9/26/13 1

4-I Equipment Maintenance Schedule (Company Owned) 3/15/16 1

4-J Red Tape Danger Sign 1/30/17 1

4-K Daily Stilt Use Area Checklist 10/12/17 1

5 HAZMAT

5-A Activity Hazard Analysis (AHA) 9/26/13 1

6 ELECTRICAL

6-A Electrical Checklist 7/27/17 2

7 FIRST AID, ACCIDENT REPORTING & EMERGENCY

7-A Exposure Control Training Form (Individual) 7/27/17 2

7-B Employee Injury Report & L&I Claim 7/27/17 2

7-C Company Accident-Incident Report 7/27/17 2

TABLE OF CONTENTS- CHECKLISTS & FORMS


7-D Jobsite Accident/Incident Report 3rd Party 7/27/17 2

7-E Supervisor’s Accident/Injury Investigation Report 7/27/17 2

7-F Written Safety Warning 7/27/17 2

8 NEAR MISS TO LESSONS LEARNED

8-A Management Near Miss Investigation 1

EMPLOYEE SAFETY ORIENTATION CHECKLIST

Company: Washington Patriot Construction, LLC Employee: Trainer: Hire Date: Date Position: Date Initials SSHO/

1. I (employee) understand the company safety program, including: Supt.

Orientation ______ ______ ______ On-the-job training ______ ______ ______ Safety meetings ______ ______ ______ Incident investigation ______ ______ ______ Disciplinary action ______ ______ ______2. Use and care of personal protective equipment (Hard hat, fall protection,

eye protection, etc.)

______

______

______

3. Line of communication and responsibility for immediately reporting injuries.

A. When to report an injury ______ ______ ______ B. How to report an injury ______ ______ ______ C. Who to report an injury to ______ ______ ______ D. Filling out incident report forms ______ ______ ______4. General overview of operation, procedures, methods and hazards as they

relate to the specific job

______

______

______

5. Pertinent safety rules of the company and DOSH ______ ______ ______

6. First aid supplies, equipment and training

A. Obtaining treatment ______ ______ ______ B. Location of Facilities ______ ______ ______ C. Location and names of First-aid trained personnel ______ ______ ______

7. Emergency plan

A. Exit location and evacuation routes ______ ______ ______ B. Use of fire fighting equipment (extinguishers, hose) ______ ______ ______ C. Specific procedures (medical, chemical, etc.) ______ ______ ______

8. Vehicle safety ______ ______ ______

9. Personal work habits

A. Serious consequences of horseplay ______ ______ ______ B. Fighting ______ ______ ______ C. Inattention ______ ______ ______ D. Smoking policy ______ ______ ______ E. Good housekeeping practices ______ ______ ______ F. Proper lifting techniques ______ ______ ______

EMPLOYEE SAFETY ORIENTATION CHECKLIST (Con’t)

Ladder Safety Checklist

Yes No Employee Training – Workers are trained to:

Keep ladders and themselves a minimum of 10 feet away from power lines

Properly set up and use ladders

Do not use ladders on uneven or slippery surfaces

Do not carry heavy objects up or down ladders

Use both hands when climbing, always face the ladder when climbing up or down, only one person is allowed on a ladder at a time, Do not step sideways from an unsecured ladder onto another object, do not stand on the top step of a step ladder

Do not use a ladder as a brace, workbench or for any other purpose than climbing

If you must place a ladder at a doorway, barricade the door to prevent its use and post a sign

If you use a ladder to get to a roof or platform, the ladder must extend at least 3 feet above the landing and be secured

Set a single or extension ladder with the base ¼ of the working ladder length away from the support.

Do not lean a step ladder against a wall and use it as a single ladder. Always unfold the ladder and lock the spreaders.

NOTE TO EMPLOYEES: Do not sign unless ALL items are covered and ALL questions are satisfactorily answered.

The signatures below document that the appropriate elements have been discussed to the satisfaction of both parties, and that both the supervisor and the employee accept responsibility for maintaining a safe and healthful work environment.

Date: _______________________ Employee Signature: ________________________

Date________________________ Supervisor’s Signature: ___________________________


DAILY SAFETY AUDIT CHECKLIST Job Name: Click here to enter text. Date: Click here to enter text. Person Inspecting: Click here to enter text. Phone Click here to enter text.

Following is a Check List to be used by individuals performing Project Site Safety Inspections. 1. Safety Commitment: Y N ☐ ☐ a. Is there a written Safety Policy Statement posted at the Jobsite? ☐ ☐ b. Who is the Designated Safety Contact for the Project: Click here to enter text. ☐ ☐ c. Is there a Washington Patriot Construction Site Specific Safety Plan at the

Project Site? ☐ ☐ d. Are there Subcontractor Site Specific Safety Plans at the Project Site? ☐ ☐ e. Are new hires required to sign a Safety Plan as part of their Orientation? 2. Site Inspection Items: N/A GENERAL SAFETY ITEMS INSPECTION COMMENTS

☐ ☐ Emergency Action Plan Posted on Site (Emergency No.) Click here to enter text.

☐ ☐ MSDS Sheets Available on Site Click here to enter text.

☐ ☐ Proper Storage of flammable liquids Click here to enter text.

☐ ☐ Fall Protection Work Plan Click here to enter text.

☐ ☐ Grounding/GFCI Program and Lockout/Tag out Procedure Click here to enter text.

☐ ☐ Qualified/Trained Operators on Site Click here to enter text.

☐ ☐ Weekly Toolbox Meeting Minutes being Conducted Click here to enter text.

☐ ☐ Safety Bulletin Board with Required Posting Click here to enter text.

☐ ☐ OSHA 300A Log (Posted February through April) Click here to enter text.

☐ ☐ First Aid/CPR training certification cards (Superintendents, Foremen) Click here to enter text.

N/A JOBSITE PROTECTIVE EQUIPMENT INSPECTION COMMENTS

☐ ☐ First Aid Kit, 2- 25 person kits Click here to enter text.

☐ ☐ Fire protection (extinguisher date and type correct for situation; Initial Tag on fire extinguisher monthly after inspection)

Click here to enter text.


N/A HOUSEKEEPING INSPECTION COMMENTS

☐ ☐ Nothing Hits the Ground Policy in Place Click here to enter text.

☐ ☐ Work Areas Clean and Orderly and Free of Trip Hazards Click here to enter text.

☐ ☐ Deck Free of Nails, Holes & Loose Boards Click here to enter text.

☐ ☐ Aisles and Walkways Clear of Obstructions Click here to enter text.

☐ ☐ Temporary Guardrails in Place where Required Click here to enter text.

☐ ☐ Trash chute for over 20’ heights Click here to enter text.

☐ ☐ Debris off ramps and other Walkways Click here to enter text.

☐ ☐ Proper Storage and Handling of Dangerous/Hazardous Mat’l Click here to enter text.

☐ ☐ Surfaces clean of water, ice, snow Click here to enter text.

N/A Personal Protective Equipment INSPECTION COMMENTS

☐ ☐ Head Protection – hard hats in use Click here to enter text.

☐ ☐ Hearing protection – ear plugs in use Click here to enter text.

☐ ☐ Leg protection – chain saw chaps Click here to enter text.

☐ ☐ Foot protection – work boots Click here to enter text.

☐ ☐ Eye and face protection – safety glasses in use Per EM385-1-1 table5-1

☐ ☐ Respiratory protection – mask dependent on exposure Click here to enter text.

☐ ☐ Fall protection – safety harness, lanyards Click here to enter text.

☐ ☐ Reflective Clothing- vest, 360 degrees Click here to enter text.

☐ ☐ Cut resistant gloves being worn Click here to enter text.

N/A SPECIFIC JOBSITE SAFETY ITEMS INSPECTION COMMENTS

☐ ☐ Proper Railings, Ramps and Stairs in place Click here to enter text.

☐ ☐ Proper use of Ladders Click here to enter text.

☐ ☐ Trenching/Excavation Depth < 5’ (also proper Access/Egress) Click here to enter text.

☐ ☐ Power Equipment properly Grounded Click here to enter text.

☐ ☐ Proper Handling/Rigging/Transportation of Materials Click here to enter text.

☐ ☐ Operation of Equipment in Safe Manner Click here to enter text.

☐ ☐ Tools being used in Proper Manner Click here to enter text.

☐ ☐ Extension cords and power equipment checked for shorts Click here to enter text.

☐ ☐ Proper Storage of Compressed Gas Cylinders Click here to enter text.

☐ ☐ Welding Operations (Flash Protection) Click here to enter text.

☐ ☐ Proper Storage of Gas and diesel fuel Click here to enter text.

☐ ☐ Appropriate Barricades in Place Click here to enter text.

☐ ☐ Potential Pinch Point Problems Click here to enter text.



☐ ☐ Back-up alarms on appropriate motorized equipment Click here to enter text.

☐ ☐ Provisions in place for Public Safety Click here to enter text.

☐ ☐ Scaffolding (rolling)


Item # Comments / Action Required Responsible Party Completion Date Click here to enter text.

Click here to enter text. Click here to enter text.

General Comments

SAFETY ACTION ITEMS


Stretch & Flex Program Sign-in

Name Signature Company/Date


WEEKLY SITE SAFETY CHECKLIST Job Name: Date: Person Inspecting: Phone:

Following is a Check List to be used by individuals performing Project Site Safety Inspections. 1. Safety Commitment: Y N ☐ ☐ a. Is there a written Safety Policy Statement posted at the Jobsite? ☐ ☐ b. Who is the Designated Safety Contact for the Project: ☐ ☐ c. Is there a W. Patriot Site Specific Safety Plan at the Project Site? ☐ ☐ d. Are there Subcontractor Site Specific Safety Plans at the Project Site? ☐ ☐ e. Are new hires required to sign a Safety Plan as part of their Orientation? 2. Site Inspection Items: N/A GENERAL SAFETY ITEMS INSPECTION COMMENTS

☐ ☐ Emergency Action Plan Posted on Site (Emergency No.)

☐ ☐ MSDS Sheets Available on Site

☐ ☐ Proper Storage of flammable liquids

☐ ☐ Fall Protection Work Plan

☐ ☐ Grounding/GFCI Program and Lockout/Tagout Procedure

☐ ☐ Qualified/Trained Operators on Site

☐ ☐ Weekly Toolbox Meeting Minutes being Conducted

☐ ☐ Safety Bulletin Board with Required Posting

☐ ☐ OSHA 300A Log (Posted February through April)

☐ ☐ First Aid/CPR training certification cards (Superintendents, Foremen)

N/A JOBSITE PROTECTIVE EQUIPMENT INSPECTION COMMENTS

☐ ☐ First Aid Kit

☐ ☐ Fire protection (extinguisher date and type correct for situation)

N/A HOUSEKEEPING INSPECTION COMMENTS

☐ ☐ Nothing Hits the Ground Policy in Place

☐ ☐ Work Areas Clean and Orderly and Free of Trip Hazards

☐ ☐ Deck Free of Nails, Holes & Loose Boards

☐ ☐ Aisles and Walkways Clear of Obstructions


☐ ☐ Temporary Guardrails in Place where Required

☐ ☐ Trash chute for over 20’ heights

☐ ☐ Debris off ramps and other Walkways

☐ ☐ Proper Storage and Handling of Dangerous/Hazardous Mat’l

☐ ☐ Surfaces clean of water, ice, snow

N/A Personal Protective Equipment INSPECTION COMMENTS

☐ ☐ Head Protection - hard hats in use

☐ ☐ Hearing protection - ear plugs in use

☐ ☐ Leg protection - chain saw chaps

☐ ☐ Foot protection - work boots

☐ ☐ Eye and face protection - safety glasses in use

☐ ☐ Respiratory protection - mask dependent on exposure

☐ ☐ Fall protection - safety harness, lanyards

☐ ☐ Reflective Clothing- vest, 360 degrees

N/A SPECIFIC JOBSITE SAFETY ITEMS INSPECTION COMMENTS

☐ ☐ Proper Railings, Ramps and Stairs in place

☐ ☐ Proper use of Ladders

☐ ☐ Trenching Depth < 4’ (also proper Access/Egress)

☐ ☐ Power Equipment properly Grounded

☐ ☐ Proper Handling/Rigging/Transportation of Materials

☐ ☐ Operation of Equipment in Safe Manner

☐ ☐ Tools being used in Proper Manner

☐ ☐ Extension cords and power equipment checked for shorts

☐ ☐ Proper Storage of Compressed Gas Cylinders

☐ ☐ Welding Operations (Flash Protection)

☐ ☐ Proper Storage of Gas and diesel fuel

☐ ☐ Appropriate Barricades in Place

☐ ☐ Potential Pinch Point Problems

☐ ☐ Back-up alarms on appropriate motorized equipment

☐ ☐ Provisions in place for Public Safety

RECOMMENDATIONS FOLLOWING INSPECTION: Site Superintendent___________________________ Print_____________________________________ Inspection by: Signature: _______________________ Print: ____________________________________

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SAFETY MEETING Project Name: 777x Dependency Labs/ Large Labs

Project Number: 9532‐9539

Date: 01/26/2015

Conducted By: Dave Isaksen

WEEKLY SAFETY TOPIC

Carbon Monoxide Include weekly safety topic narrative in this cell. An example has been provided, which was cut and pasted from the L&I website:

Sources of Carbon Monoxide in the Workplace

Carbon monoxide (CO) is a colorless, odorless gas produced by all internal combustion engines, including diesel and propane‐powered engines. It is also produced by burning wood, paper, or plastic products and from welding when carbon dioxide shielding gas is used.

Workers can be exposed to carbon monoxide in warehouses and in fruit and seafood packing facilities where propane‐powered forklifts are operated. Exposure can also occur when operating equipment with small gasoline engines, such as pressure washers, concrete cutters, water pumps, air compressors, and generators at construction sites. CO is also produced from kerosene space heaters (salamanders), natural gas cooking units, and propane‐powered floor polishers. Outdoor use of any of this equipment is not usually hazardous but in buildings or enclosed spaces, carbon monoxide can quickly build up to dangerous and even deadly amounts.

It doesn’t take much CO to cause problems. Depending upon the amount of carbon monoxide in the air, symptoms could include‐‐‐but are not limited to‐‐‐slight headache, fatigue, nausea, dizziness, shortness of breath, errors in judgment, confusion, convulsions, collapse, and even death.

At lower levels, people sometimes mistake the symptoms of CO exposure for the flu, or do not associate their severe headache and nausea with carbon monoxide exposure.

People with heart or lung conditions or other health problems can be more sensitive to the effects of carbon monoxide. In addition the fetus of a pregnant woman can be adversely affected by carbon monoxide she inhales. For this reason WISHA Permissible limits for carbon monoxide are 35 ppm averaged over 8 hours with a 200 ppm ceiling limit.

KEEP JOB SITE CLEAN AT ALL TIMES

Report Accidents to WA Patriot IMMEDIATELY

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JOB SITE SAFETY REQUIREMENTS – ALL PROJECTS Personal Protection

100% Hard hats (worn properly), eye protection, high visibility safety shirt or vest, work boots

Ear and dust protection used when appropriate

Proper PPE for the activity‐‐‐e.g. resistant cut gloves when working with sheet metal, flashing, rebar, etc.

PPE inspections required prior to beginning work

Radios or earbuds are not permitted on job site

Tools, Equipment, & Materials

Equipment inspections required prior to use

Tool inspections required prior to use

Use proper lifting/storage techniques for materials and equipment

Only trained employees may operate equipment‐‐‐certification may be required for specific equipment

Use spotter when moving equipment through building

Hot Work Permit required for any spark producing task

GFCI must be used

Notify WA Patriot if any loud or dusty work is anticipated

Work Areas

Review and verify barriers are maintained

Clean up work areas & surrounding areas daily

Close dumpsters, use safety chain when open

No smoking/ use of tobacco products

Inform WA patriot immediately if any trade damage occurs

JOB SITE SAFETY REQUIREMENTS – PROJECT SPECIFIC Personal Protection

Tools, Equipment, & Materials

Work Areas

No smoking/ use of tobacco products on Boeing property

Coordinate with Boeing staff during co‐occupancy

ACTIVITIES SCHEDULED THIS WEEK – JOB SPECIFIC SAFETY REMINDE

ACTIVITY ACTIVITY SAFETY REMINDERS

AP0‐ Downstairs: Continue framing for sound panel and continue ceiling installation

Be aware of work overhead. Delineate work area if necessary to ensure the safety of co‐workers.

AP0‐ 2nd Floor: Continue Elec/Mech work, cab platform steel erection finish, HVAC install at new scaffold area.

Scaffold Safety Review Daily

Power Upgrades: High Bay overhead steel installation continues for conduit runs.

Continue Daily crew meeting prior to start of activities to ensure all are aware of the potential hazards when working with the scaffold crew.

EPSL: HVAC, Electrical rough‐in continues. Steel erection on roof. Roof penetrations are nearly complete.

Make sure fire watch is present in all areas where performing hot work.

ITV: Monocote starts today. Remove your materials from ITV structure to avoid monocote coverage!

See a hazard? Fix and/or notify Washington Patriot Construction IMMEDIATELY

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Drive Stands: Certification testing. No work scheduled until certification is complete.

Coordinate activities at 6:30am scheduling and coordination meeting DAILY

SAFETY LESSONS LEARNED TO CARRY FORWARD

Employ extra spotters when concrete pump‐truck boom is in close proximity to crane‐rails or any other overhead hazards. The spotters should be watching 100% of the time‐‐‐Full‐Time.

Always be on the lookout for potential hazards ‐ even the small items can potentially be deadly

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Safety Topic: Aerial Lift Date: 2‐08‐2016

SAFTEY MEETING ATTENDEES

NAME (PRINT) SIGNATURE COMPANY

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Minutes Taken By:

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Safety Topic: Aerial Lift Date: 2‐08‐2016

SAFTEY MEETING ATTENDEES

NAME (PRINT) SIGNATURE COMPANY

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Minutes Taken By:

List steps to complete task:

Possible obtsacles to consider:

Working above someone?

Working below someone?

Working near someone/Horizontal plane

Are you in a jointly occupied space?

What is the worst outcome from your task?

Do you have the information to complete task?

YES NO

What information do you need?

List hazards associated with each step:

Possible hazards to consider:

Dropped items

Hit by dropped item

Hit by object/trip hazards

Do you have the safety equipment to complete task?

YES NO

What safety equipment do you need?

Ways to eliminate or control hazards:

Possible solutions to eliminate hazards:

Protect the area above/below the work

Delineate the area. Activity below the

overhead work area should stop unless

protected.

Communicate with employees in the area.

Do you have the materials to complete task?

YES NO

What materials do you need?

Permit Required/Competent Person Confined Space Scaffold/Erect/Insp

Hot work Crane/Rigging/critical lift

Energized electrical work Excavation

General Checklist YES NO NA

MSDS reviewed/needed for task?

Proper safety equipment on job site?

Electrical hot work equipment up‐to‐date?

Confined space procedure/ rescue plan?

Utility lines located above/ below ground?

All fall protection equipment inspected?

Emergency procedure and contacts?

Work communicated with others in area?

New Employee Buddy System?

Material Handling Checklist Is the item being lifted weigh more than 50lb

(If it is use get help or use lift)

Has stretch and flex been performed?

Are you following safe lifting procedures?

Are the proper gloves being used?

Is Spotter being used?

Forklift/Equipment checklist complete?

Certified Opperators card?

Ladder Safety Checklist What is the height of the work being performed?

What is the height of the ladder being used?

Ladder inspected and updated?

Ladder set up on stable ground?

Is the work area clear round the ladder?

Lock Out/ Tag Out Checklist Is a lock out required?

Has the system been walked down?

Has owner isolated system and placed lock?

Is your lock placed?

Has the system been test started?

End of Task Checklist All equipment shut down

Cylinders capped and secured including propane on equip.

All tools/ materials removed and properly stored

Work area cleaned up

All LOTO tags released and signed off

Permits turned in

Completed task status communicated to foreman

Possible Hazards (List Details on Back of Card)

Chemical Burn

Thermal Burn

Particles In Eye

Overexertion

Elevated Work

Overhead Work

Dropping Materials

Inhalation of Hazardous Substances

Vehicle Collisions

Cuts

Fire

Spills

Abrasions

Cave‐In

Loud Noises

Heat Stress

Traffic Control

Joint occupancy

Lifting Material with Crane

Ways to Eliminate Hazards (List Details on Back of Card)

Rubber gloves, face shield, flash suit

Delineation

Overhead protection/netting

Fall protection plan

Alternate Shift

Appropriate gloves

Eye/ face protection

Adequate staff to complete task

Tool lanyards

Hearing protection

Housekeeping

Proper tool for the job

Electrical cords and welding leads off floor or protected

Barricades with signs in place

Close all openings in roof/Hatches included

Fire extinguisher available

Get additional training for task

Correct body position for task

Competent person for shoring or safe slope

Stretch and flex

Competent person for scaffolding

Chemical containment / spill kit

Use a scaffold and man‐lift check list

Drive to work safely

Communicate with team – huddle up

WASH I N G T O N P A T R I O T CON S T R U C T I O N

PRE‐TASK PLAN Job Number:

Superintendent:

Company:

Date Started: Time:

Date Completed: Time:

Safety Goals

Zero people hurt

No disruption to facility or environment

Task Name

Answer Questions on back Are you working above anyone?

Are you working below anyone?

Are you working near anyone?

Are you in a shared space

What is the worst outcome possible?

Have you reviewed this with a supervisor?

Crew Names Printed

Reviewed by Date


Medical Evaluation Questionnaire For Respirator Users

Part 1 Employer Instructions:

You may use on-line questionnaires if the requirements in WAC 296-842-14005 are met. You must tell your employee how to deliver or send the completed questionnaire to the health care

provider you have selected. You must not review employees’ questionnaires.

Health care provider’s instructions:

Review the information in this questionnaire and any additional information provided to you by the employer.

You may add questions to this questionnaire at your discretion; however, questions in Parts 1-3 may not be deleted or substantially altered.

Follow-up evaluation is required for any positive response to questions 1-8 in Part 2 or questions 1-6 in Part 3. This might include: phone consultations to evaluate positive responses, medical tests, and diagnostic procedures.

When your evaluation is complete, send a copy of your written recommendation to the employer and employee.

Employee information and instructions:

Your employer must allow you to answer this questionnaire during normal working hours, or at a time and place that is convenient to you.

Your employer or supervisor must not look at or review your answers at any time. Res

Part 1-Employee Background Information (ALL employees must complete this part) Please print

1. Today’s date: Click here to enter a date. Your name :Click here to enter text.

2. Your age (to nearest year):Click here to enter text.

3. Sex (check one):☐ Male / ☐ Female

4. Your height: Click here to enter text.ft. Click here to enter text. in. Your weight: Click here to enter text. lbs.

5. Your job title: Click here to enter text. 6. A phone number where you can be reached by the health care professional who reviews this

questionnaire (include Area Code): Click here to enter text.

7. The best time to call you at this number: Click here to enter text.

8. Has your employer told you how to contact the health care professional who will review this questionnaire? ☐ Yes ☐ No

9. Check the type of respirator(s) you will be using:

a. ☐ N, R, or P filtering facepiece respirator (for example, a dust mask, OR an N95 filtering facepiece respirator).

b. Check all that apply.

☐ Half mask / ☐ Full facepiece mask / ☐Helmet hood Escape / ☐Supplied-air or Air-line ☐ Non-powered cartridge or canister / ☐ Powered air-purifying cartridge resp. (PAPR) ☐Self contained breathing apparatus (SCBA):


☐ Demand or Pressure demand / ☐ Other: Click here to enter text. 10. Have you previously worn a respirator? ☐ Yes ☐ No If “yes,” describe what type(s Click here to enter text.

Part 2-General Health Information (ALL employees must complete this part) Please check “Yes” or “No”

1. Do you smoke tobacco, or have you smoked tobacco in the last month? ☐ Yes ☐ No 2. Have you ever had any of the following conditions?

a. Seizures (fits): ☐Yes ☐No b. Diabetes (sugar disease): ☐Yes ☐No c. Allergic reactions that interfere with your breathing: ☐Yes ☐No d. Claustrophobia (fear of closed-in places): ☐Yes ☐No e. Trouble smelling odors: ☐Yes ☐No

3. Have you ever had any of the following pulmonary or lung problems? a. Asbestosis: ☐Yes ☐No b. Asthma: ☐Yes ☐No c. Chronic bronchitis: ☐Yes ☐No d. Emphysema: ☐Yes ☐No e. Pneumonia: ☐Yes ☐No f. Tuberculosis: ☐Yes ☐No g. Silicosis: ☐Yes ☐No h. Pneumothorax (collapsed lung): ☐Yes ☐No i. Lung cancer: ☐Yes ☐No j. Broken ribs: ☐Yes ☐No k. Any chest injuries or surgeries: ☐Yes ☐No l. Any other lung problem that you have been told about: ☐Yes ☐No

4. Do you currently have any of the following symptoms of pulmonary or lung illness?

a. Shortness of breath: ☐Yes ☐No b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline: ☐Yes

☐No c. Shortness of breath when walking with other people at an ordinary pace on level ground: ☐Yes

☐No d. Have to stop for breath when walking at your own pace on level ground: ☐Yes ☐No e. Shortness of breath when washing or dressing yourself: ☐Yes ☐No f. Shortness of breath that interferes with your job: ☐Yes ☐No g. Coughing that produces phlegm (thick sputum): ☐Yes ☐No h. Coughing that wakes you early in the morning: ☐Yes ☐No i. Coughing that occurs mostly when you are lying down: ☐Yes ☐No j. Coughing up blood in the last month: ☐Yes ☐No k. Wheezing: ☐Yes ☐No l. Wheezing that interferes with your job: ☐Yes ☐No m. Chest pain when you breathe deeply: ☐Yes ☐No n. Any other symptoms that you think may be related to lung problems: ☐Yes ☐No

5. Have you ever had any of the following cardiovascular or heart problems?

a. Heart attack: ☐Yes ☐No b. Stroke: ☐Yes ☐No c. Angina: ☐Yes ☐No d. Heart failure: ☐Yes ☐No e. Swelling in your legs or feet (not caused by walking): ☐Yes ☐No f. Heart arrhythmia (heart beating irregularly): ☐Yes ☐No


g. High blood pressure: ☐Yes ☐No h. Any other heart problem that you have been told about: ☐Yes ☐No

6. Have you ever had any of the following cardiovascular or heart symptoms?

a. Frequent pain or tightness in your chest: ☐Yes ☐No b. Pain or tightness in your chest during physical activity: ☐Yes ☐No c. Pain or tightness in your chest that interferes with your job: ☐Yes ☐No d. In the past 2 years, have you noticed your heart skipping or missing a beat: ☐Yes ☐No e. Heartburn or indigestion that isn't related to eating: ☐Yes ☐No f. Any other symptoms that you think may be related to heart or circulation problems: ☐Yes ☐No

7. Do you currently take medication for any of the following problems?

a. Breathing or lung problems: ☐Yes ☐No b. Heart trouble: ☐Yes ☐No c. Blood pressure: ☐Yes ☐No d. Seizures (fits): ☐Yes ☐No

8. If you have used a respirator, have you ever had any of the following problems? (If you have never used

a respirator, check the following space and go to question 9 a. Eye irritation: ☐Yes ☐No b. Skin allergies or rashes: ☐Yes ☐No c. Anxiety: ☐Yes ☐No d. General weakness or fatigue: ☐Yes ☐No e. Any other problem that interferes with your use of a respirator? ☐Yes ☐No

9. Would you like to talk to the health care professional who will review this questionnaire about your

answers? ☐Yes ☐No

Part 3-Additional Questions for Users of Full-facepiece Respirators or SCBAs Please check “Yes” or “No”

1. Have you ever lost vision in either eye (temporarily or permanently): ☐Yes ☐No 2. Do you currently have any of these vision problems?

a. Need to wear contact lenses: ☐Yes ☐No b. Need to wear glasses: ☐Yes ☐No c. Color blindness: ☐Yes ☐No d. Any other eye or vision problem: ☐Yes ☐No

3. Have you ever had an injury to your ears, including a broken ear drum: ☐Yes ☐No 4. Do you currently have any of these hearing problems?

a. Difficulty hearing: ☐Yes ☐No b. Need to wear a hearing aid: ☐Yes ☐No c. Any other hearing or ear problem: ☐Yes ☐No

5. Have you ever had a back injury: ☐Yes ☐No

6. Do you currently have any of the following musculoskeletal problems?

a. Weakness in any of your arms, hands, legs, or feet: ☐Yes ☐No b. Back pain: ☐Yes ☐No c. Difficulty fully moving your arms and legs: ☐Yes ☐No d. Pain or stiffness when you lean forward or backward at the waist: ☐Yes ☐No e. Difficulty fully moving your head up or down: ☐Yes ☐No


f. Difficulty fully moving your head side to side: ☐Yes ☐No g. Difficulty bending at your knees: ☐Yes ☐No h. Difficulty squatting to the ground: ☐Yes ☐No i. Climbing a flight of stairs or a ladder carrying more than 25 lbs: ☐Yes ☐No j. Any other muscle or skeletal problem that interferes with using a respirator: ☐Yes ☐No

Part 4-Discretionary Questions Complete questions in this part only if your employer’s health care provider says they are necessary

1. In your present job, are you working at high altitudes (over 5,000 feet) or in a place that has lower than normal amounts of oxygen? ☐Yes ☐No

If “yes,” do you have feelings of dizziness, shortness of breath, pounding in your chest, or other symptoms when you are working under these conditions: ☐Yes ☐No

2. Have you ever been exposed (at work or home) to hazardous solvents, hazardous airborne chemicals (such as, gases, fumes, or dust), or have you come into skin contact with hazardous chemicals? ☐Yes ☐No

3. If “yes,” name the chemicals, if you know them: Click here to enter text. Have you ever worked with any of the materials, or under any of the conditions, listed below: a. Asbestos? ☐Yes ☐No b. Silica (for example, in sandblasting)? ☐Yes ☐No c. Tungsten/cobalt (for example, grinding or welding this material)? ☐Yes ☐No d. Beryllium? ☐Yes ☐No e. Aluminum? ☐Yes ☐No f. Coal (for example, mining)? ☐Yes ☐No g. Iron? ☐Yes ☐No h. Tin? ☐Yes ☐No i. Dusty environments? ☐Yes ☐No j. Any other hazardous exposures? ☐Yes ☐No If “yes,” describe these exposures: Click here to enter text. List any second jobs or side businesses you have: Click here to enter text. List your previous occupations: Click here to enter text. List your current and previous hobbies: Click here to enter text. Have you been in the military services? ☐Yes ☐No If “yes,” were you exposed to biological or chemical agents (either in training or combat)? ☐Yes ☐No

4. Have you ever worked on a HAZMAT team? ☐Yes ☐No Will you be using any of the following items with your respirator(s)? a. HEPA Filters: ☐Yes ☐No b. Canisters (for example, gas masks): ☐Yes ☐No c. Cartridges: ☐Yes ☐No

5. Other than medications for breathing and lung problems, heart trouble, blood pressure, and seizures

mentioned earlier in this questionnaire, are you taking any other medications for any reason (including over-the-counter medications)? ☐Yes ☐No If Yes, name the medications if you know them: Click here to enter text.

6. How often are you expected to use the respirator(s)? a. Escape-only (no rescue): ☐Yes ☐No b. Emergency rescue only: ☐Yes ☐No c. Less than 5 hours per week: ☐Yes ☐No d. Less than 2 hours per day: ☐Yes ☐No e. 2 to 4 hours per day: ☐Yes ☐No f. Over 4 hours per day: ☐Yes ☐No


7. During the period you are using the respirator(s), is your work effort:

a. Light (less than 200 kcal per hour): ☐Yes ☐No If “yes,” how long does this period last during the average shift: Click here to eter text.hrs. Click here to enter text.mins. Examples of a light work effort are sitting while writing, typing, drafting, or performing light assembly work; or standing while operating a drill press (1-3 lbs.) or controlling machines. b. Moderate (200 to 350 kcal per hour): ☐Yes ☐No If “yes,” how long does this period last during the average shift:Enter # hrs.Enter # mins. Examples of moderate work effort are sitting while nailing or filing; driving a truck or bus in urban traffic; standing while drilling, nailing, performing assembly work, or transferring a moderate load (about 35 lbs.)at trunk level; walking on a level surface about 2 mph or down a 5-degree grade about 3 mph; or pushing a wheelbarrow with a heavy load (about 100 lbs.) on a level surface. c. Heavy (above 350 kcal per hour): ☐Yes ☐No If “yes,” how long does this period last during the average shift_______hrs.______mins. Examples of heavy work are lifting a heavy load (about 50 lbs.) from the floor to your waist or shoulder; working on a loading dock; shoveling; standing while bricklaying or chipping castings; walking up an 8-degree grade about 2 mph; climbing stairs with a heavy load (about 50 lbs.)

8. Will you be wearing protective clothing and/or equipment (other than the respirator) when you are using your respirator: ☐Yes ☐No If “yes,” describe this protective clothing and/or equipment:________________________ ______________________________________________________________________

9. Will you be working under hot conditions (temperature exceeding 77°F): ☐Yes ☐No

10. Will you be working under humid conditions: ☐Yes ☐No

11. Describe the work you will be doing while using your respirator(s):___________________ _________________________________________________________________________

12. Describe any special or hazardous conditions you might encounter when you are using your respirator(s) (for example, confined spaces, life-threatening gases): ___________________ __________________________________________________________________________

13. Provide the following information, if you know it, for each toxic substance that you will be exposed to when you are using your respirator(s): Name of the first toxic substance: ___________________________________________ Estimated maximum exposure level per shift:__________________________________ Duration of exposure per shift:______________________________________________ Name of the second toxic substance:_________________________________________ Estimated maximum exposure level per shift:__________________________________ Duration of exposure per shift:______________________________________________ Name of the third toxic substance:___________________________________________ Estimated maximum exposure level per shift:__________________________________ Duration of exposure per shift:______________________________________________ The name of any other toxic substances that you will be exposed to while using your respirator:_____________________________________________________________ ______________________________________________________________________

14. Describe any special responsibilities you will have while using your respirator(s) that may affect the safety and well being of others (for example, rescue, security). ______________________________________________________________________ ______________________________________________________________________


Medical Evaluation Questionnaire For Respirator Users

Part 1 Employer Instructions:

You may use on-line questionnaires if the requirements in WAC 296-842-14005 are met. You must tell your employee how to deliver or send the completed questionnaire to the health care

provider you have selected. You must not review employees’ questionnaires.

Health care provider’s instructions:

Review the information in this questionnaire and any additional information provided to you by the employer.

You may add questions to this questionnaire at your discretion; however, questions in Parts 1-3 may not be deleted or substantially altered.

Follow-up evaluation is required for any positive response to questions 1-8 in Part 2 or questions 1-6 in Part 3. This might include: phone consultations to evaluate positive responses, medical tests, and diagnostic procedures.

When your evaluation is complete, send a copy of your written recommendation to the employer and employee.

Employee information and instructions:

Your employer must allow you to answer this questionnaire during normal working hours, or at a time and place that is convenient to you.

Your employer or supervisor must not look at or review your answers at any time. Res

Part 1-Employee Background Information (ALL employees must complete this part) Please print

1. Today’s date:___________ Your name:____________________________________

2. Your age (to nearest year):_________________

3. Sex (circle one): Male / Female

4. Your height: __________ft.__________in. Your weight: ____________lbs.

5. Your job title:__________________________________

6. A phone number where you can be reached by the health care professional who reviews this questionnaire (include Area Code):___________________________

7. The best time to call you at this number:_____________________

8. Has your employer told you how to contact the health care professional who will review this questionnaire? Yes No

9. Check the type of respirator(s) you will be using:

a. ____N, R, or P filtering facepiece respirator (for example, a dust mask, OR an N95 filtering facepiece respirator).

b. Circle all that apply.

Half mask / Full facepiece mask / Helmet hood Escape / Supplied-air or Air-line Non-powered cartridge or canister / Powered air-purifying cartridge resp. (PAPR) Self contained breathing apparatus (SCBA): Demand or Pressure demand / Other:_________________________________


10. Have you previously worn a respirator? Yes No If “yes,” describe what type(s):_______________________________________________________ ________________________________________________________________________________

Part 2-General Health Information (ALL employees must complete this part) Please check “Yes” or “No”

1. Do you smoke tobacco, or have you smoked tobacco in the last month? Yes No 2. Have you ever had any of the following conditions?

a. Seizures (fits): ☐Yes ☐No b. Diabetes (sugar disease): ☐Yes ☐No c. Allergic reactions that interfere with your breathing: ☐Yes ☐No d. Claustrophobia (fear of closed-in places): ☐Yes ☐No e. Trouble smelling odors: ☐Yes ☐No

3. Have you ever had any of the following pulmonary or lung problems? a. Asbestosis: ☐Yes ☐No b. Asthma: ☐Yes ☐No c. Chronic bronchitis: ☐Yes ☐No d. Emphysema: ☐Yes ☐No e. Pneumonia: ☐Yes ☐No f. Tuberculosis: ☐Yes ☐No g. Silicosis: ☐Yes ☐No h. Pneumothorax (collapsed lung): ☐Yes ☐No i. Lung cancer: ☐Yes ☐No j. Broken ribs: ☐Yes ☐No k. Any chest injuries or surgeries: ☐Yes ☐No l. Any other lung problem that you have been told about: ☐Yes ☐No

4. Do you currently have any of the following symptoms of pulmonary or lung illness?

a. Shortness of breath: ☐Yes ☐No b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline: ☐Yes

☐No c. Shortness of breath when walking with other people at an ordinary pace on level ground: ☐Yes

☐No d. Have to stop for breath when walking at your own pace on level ground: ☐Yes ☐No e. Shortness of breath when washing or dressing yourself: ☐Yes ☐No f. Shortness of breath that interferes with your job: ☐Yes ☐No g. Coughing that produces phlegm (thick sputum): ☐Yes ☐No h. Coughing that wakes you early in the morning: ☐Yes ☐No i. Coughing that occurs mostly when you are lying down: ☐Yes ☐No j. Coughing up blood in the last month: ☐Yes ☐No k. Wheezing: ☐Yes ☐No l. Wheezing that interferes with your job: ☐Yes ☐No m. Chest pain when you breathe deeply: ☐Yes ☐No n. Any other symptoms that you think may be related to lung problems: ☐Yes ☐No

5. Have you ever had any of the following cardiovascular or heart problems?

a. Heart attack: ☐Yes ☐No b. Stroke: ☐Yes ☐No c. Angina: ☐Yes ☐No d. Heart failure: ☐Yes ☐No e. Swelling in your legs or feet (not caused by walking): ☐Yes ☐No f. Heart arrhythmia (heart beating irregularly): ☐Yes ☐No g. High blood pressure: ☐Yes ☐No


h. Any other heart problem that you have been told about: ☐Yes ☐No

6. Have you ever had any of the following cardiovascular or heart symptoms? a. Frequent pain or tightness in your chest: ☐Yes ☐No b. Pain or tightness in your chest during physical activity: ☐Yes ☐No c. Pain or tightness in your chest that interferes with your job: ☐Yes ☐No d. In the past 2 years, have you noticed your heart skipping or missing a beat: ☐Yes ☐No e. Heartburn or indigestion that isn't related to eating: ☐Yes ☐No f. Any other symptoms that you think may be related to heart or circulation problems: ☐Yes ☐No

7. Do you currently take medication for any of the following problems?

a. Breathing or lung problems: ☐Yes ☐No b. Heart trouble: ☐Yes ☐No c. Blood pressure: ☐Yes ☐No d. Seizures (fits): ☐Yes ☐No

8. If you have used a respirator, have you ever had any of the following problems? (If you have never used

a respirator, check the following space and go to question 9 a. Eye irritation: ☐Yes ☐No b. Skin allergies or rashes: ☐Yes ☐No c. Anxiety: ☐Yes ☐No d. General weakness or fatigue: ☐Yes ☐No e. Any other problem that interferes with your use of a respirator? ☐Yes ☐No

9. Would you like to talk to the health care professional who will review this questionnaire about your

answers? ☐Yes ☐No

Part 3-Additional Questions for Users of Full-facepiece Respirators or SCBAs Please check “Yes” or “No”

1. Have you ever lost vision in either eye (temporarily or permanently): ☐Yes ☐No 2. Do you currently have any of these vision problems?

a. Need to wear contact lenses: ☐Yes ☐No b. Need to wear glasses: ☐Yes ☐No c. Color blindness: ☐Yes ☐No d. Any other eye or vision problem: ☐Yes ☐No

3. Have you ever had an injury to your ears, including a broken ear drum: ☐Yes ☐No 4. Do you currently have any of these hearing problems?

a. Difficulty hearing: ☐Yes ☐No b. Need to wear a hearing aid: ☐Yes ☐No c. Any other hearing or ear problem: ☐Yes ☐No

5. Have you ever had a back injury: ☐Yes ☐No

6. Do you currently have any of the following musculoskeletal problems?

a. Weakness in any of your arms, hands, legs, or feet: ☐Yes ☐No b. Back pain: ☐Yes ☐No c. Difficulty fully moving your arms and legs: ☐Yes ☐No d. Pain or stiffness when you lean forward or backward at the waist: ☐Yes ☐No e. Difficulty fully moving your head up or down: ☐Yes ☐No f. Difficulty fully moving your head side to side: ☐Yes ☐No


g. Difficulty bending at your knees: ☐Yes ☐No h. Difficulty squatting to the ground: ☐Yes ☐No i. Climbing a flight of stairs or a ladder carrying more than 25 lbs: ☐Yes ☐No j. Any other muscle or skeletal problem that interferes with using a respirator: ☐Yes ☐No

Part 4-Discretionary Questions Complete questions in this part only if your employer’s health care provider says they are necessary

1. In your present job, are you working at high altitudes (over 5,000 feet) or in a place that has lower than normal amounts of oxygen? ☐Yes ☐No

If “yes,” do you have feelings of dizziness, shortness of breath, pounding in your chest, or other symptoms when you are working under these conditions: ☐Yes ☐No

2. Have you ever been exposed (at work or home) to hazardous solvents, hazardous airborne chemicals (such as, gases, fumes, or dust), or have you come into skin contact with hazardous chemicals? ☐Yes ☐No

3. If “yes,” name the chemicals, if you know them:_________________________________ ______________________________________________________________________

4. Have you ever worked with any of the materials, or under any of the conditions, listed below: a. Asbestos? ☐Yes ☐No b. Silica (for example, in sandblasting)? ☐Yes ☐No c. Tungsten/cobalt (for example, grinding or welding this material)? ☐Yes ☐No d. Beryllium? ☐Yes ☐No e. Aluminum? ☐Yes ☐No f. Coal (for example, mining)? ☐Yes ☐No g. Iron? ☐Yes ☐No h. Tin? ☐Yes ☐No i. Dusty environments? ☐Yes ☐No j. Any other hazardous exposures? ☐Yes ☐No If “yes,” describe these exposures:____________________________________________

List any second jobs or side businesses you have:______________________________ ______________________________________________________________________

5. List your previous occupations:______________________________________________ ______________________________________________________________________

6. List your current and previous hobbies:________________________________________ ______________________________________________________________________

7. Have you been in the military services? ☐Yes ☐No If “yes,” were you exposed to biological or chemical agents (either in training or combat)? ☐Yes ☐No

8. Have you ever worked on a HAZMAT team? ☐Yes ☐No Will you be using any of the following items with your respirator(s)? a. HEPA Filters: ☐Yes ☐No b. Canisters (for example, gas masks): ☐Yes ☐No c. Cartridges: ☐Yes ☐No

9. Other than medications for breathing and lung problems, heart trouble, blood pressure, and seizures

mentioned earlier in this questionnaire, are you taking any other medications for any reason (including over-the-counter medications)? ☐Yes ☐No If Yes, name the medications if you know them: ______________________________________ _____________________________________________________________________________

10. How often are you expected to use the respirator(s)? a. Escape-only (no rescue): ☐Yes ☐No b. Emergency rescue only: ☐Yes ☐No c. Less than 5 hours per week: ☐Yes ☐No d. Less than 2 hours per day: ☐Yes ☐No


e. 2 to 4 hours per day: ☐Yes ☐No f. Over 4 hours per day: ☐Yes ☐No

11. During the period you are using the respirator(s), is your work effort: a. Light (less than 200 kcal per hour): ☐Yes ☐No If “yes,” how long does this period last during the average shift: _______hrs. _____mins. Examples of a light work effort are sitting while writing, typing, drafting, or performing light assembly work; or standing while operating a drill press (1-3 lbs.) or controlling machines. b. Moderate (200 to 350 kcal per hour): ☐Yes ☐No If “yes,” how long does this period last during the average shift:_____hrs._______mins. Examples of moderate work effort are sitting while nailing or filing; driving a truck or bus in urban traffic; standing while drilling, nailing, performing assembly work, or transferring a moderate load (about 35 lbs.)at trunk level; walking on a level surface about 2 mph or down a 5-degree grade about 3 mph; or pushing a wheelbarrow with a heavy load (about 100 lbs.) on a level surface. c. Heavy (above 350 kcal per hour): ☐Yes ☐No If “yes,” how long does this period last during the average shift_______hrs.______mins. Examples of heavy work are lifting a heavy load (about 50 lbs.) from the floor to your waist or shoulder; working on a loading dock; shoveling; standing while bricklaying or chipping castings; walking up an 8-degree grade about 2 mph; climbing stairs with a heavy load (about 50 lbs.)

12. Will you be wearing protective clothing and/or equipment (other than the respirator) when you are using your respirator: ☐Yes ☐No If “yes,” describe this protective clothing and/or equipment:________________________ ______________________________________________________________________

13. Will you be working under hot conditions (temperature exceeding 77°F): ☐Yes ☐No

14. Will you be working under humid conditions: ☐Yes ☐No

15. Describe the work you will be doing while using your respirator(s):___________________ _________________________________________________________________________

16. Describe any special or hazardous conditions you might encounter when you are using your respirator(s) (for example, confined spaces, life-threatening gases): ___________________ __________________________________________________________________________

17. Provide the following information, if you know it, for each toxic substance that you will be exposed to when you are using your respirator(s): Name of the first toxic substance: ___________________________________________ Estimated maximum exposure level per shift:__________________________________ Duration of exposure per shift:______________________________________________ Name of the second toxic substance:_________________________________________ Estimated maximum exposure level per shift:__________________________________ Duration of exposure per shift:______________________________________________ Name of the third toxic substance:___________________________________________ Estimated maximum exposure level per shift:__________________________________ Duration of exposure per shift:______________________________________________ The name of any other toxic substances that you will be exposed to while using your respirator:_____________________________________________________________ ______________________________________________________________________

18. Describe any special responsibilities you will have while using your respirator(s) that may affect the safety and well being of others (for example, rescue, security). ______________________________________________________________________ ______________________________________________________________________


Confined Space Entry Permit

PERMIT VALID FOR 8 HOURS ONLY. ALL PERMIT COPIES MUST REMAIN AT THE SITE UNTIL JOB IS COMPLETED.

Date: Click here to enter a date.

Site location /description: Click here to enter text.

Purpose of entry: Click here to enter text.

Supervisor (s) in charge of crews


Type of Crew


Telephone # Click here to enter text.

Communication procedures: Click here to enter text.

___________________________________________________________________________________ Rescue procedures (telephone number at bottom): Click here to enter text.

BOLD INDICATES MINIMUM REQUIREMENTS TO COMPLETE AND REVIEW PRIOR TO

ENTRY (Note: For Items that do not apply, enter N/A in the blank) REQUIREMENTS

COMPLETED DATE TIME REQUIREMENTS

COMPLETED DATE TIME

Lockout/De-energize/Tagout



Full Body Harness w/"D" Ring Click here to enter text.


Line(s) Broken-Capped-Blank



Emergency Escape Retrieval Equipment



Purge-Flush and Vent Click here to enter text.


Lifelines Click here to enter text.


Ventilation Click here to enter text.


Fire Extinguishers Click here to enter text.


Secure Area (Post and Flag)

Click here to

Click here to

Lighting (Explosive proof) Click here to enter text.

Click here to


enter text.

enter text.

enter text.

Breathing Apparatus Click here to enter text.


Protective Clothing Click here to enter text.


Resuscitator - Inhalator Click here to enter text.


Respirator(s) (Air Purifying) Click here to enter text.


Standby Safety Personnel Click here to enter text.


Burning and Welding Permit Click here to enter text.


Continuous Monitoring: ☐ Yes ☐ No

Periodic Monitoring Frequency: Click here to enter text.

Test(s) Permissible entry level

Percent of oxygen 19.5% TO 23.5%

Lower flammable limit Under 10%

Carbon monoxide +35 PPM

Aromatic Hydrocarbon +1 PPM *5 PPM

Hydrogen Cyanide (Skin) *4 PPM

Hydrogen Sulfide +10 PPM *15 PPM Sulfur Dioxide +2 PPM *5 PPM Ammonia * 35 PPM * Short-term exposure limit: Employees can work in the area up to 15 minutes.

+ 8 hour Time Weighted Average: Employees can work in the area 8 hours (longer with appropriate respiratory protection).

REMARKS: Click here to enter text.

Gas Tester Name & Check # Click here to enter text. Instructions Used Click here to enter text. Model &/or Type Click here to enter text. Serial &/or Unit # Click here to enter text.


SAFETY STANDBY IS REQUIRED FOR ALL CONFINED SPACE WORK

Safety Standby Person(s) Check # Click here to enter text. Press enter to add additional entries

Click here to enter text. Press enter to add additional entries

Confined Space Entrant(s) Check # Click here to enter text. Press enter to add additional entries

Click here to enter text. Press enter to add additional entries

SUPERVISOR AUTHORIZATION - ALL CONDITIONS SATISFIED:

Department or phone number: Click here to enter text. Signature________________________________

EMERGENCY CONTACT PHONE NUMBERS:

Ambulance: Click here to enter text.

Fire: Click here to enter text.

Safety: Click here to enter text.

Gas coordinator: Click here to enter text.


Employee Fall Arrest and Restraint Training Job Number Click here to enter text. Job Name Click here to enter text.

All employees on jobsites where a fall protection plan is in place shall be given fall arrest and restraint training.

The training shall be given by a person competent in the hazards of falls and in the use of fall protection

equipment including the 10 points outlined in this form. This form is to be posted on the jobsite or kept with the

supervisor while on the jobsite.

I have received training in the use of fall arrest and restraint equipment which included:

1. Hazard recognition in the areas of potential fall hazards in the work area and information on the actual

identified hazards on this site.

2. The employee’s role in the fall protection program.

3. The regulations concerning fall protection.

4. Methods of fall protection and fall restraint.

5. Procedures for erecting, assembly, handling, inspection, maintenance and disassembly of fall protection

systems.

6. The employee’s role in safety monitoring systems for leading edge protection.

7. Procedures for the handling and storage of tools and materials.

8. Communication procedures.

9. Overhead protection.

10. Rescue procedures.

Employees Must Sign Below

Sign Print Date________





Competent Person Signature_____________________________ Date_____________


Fall Protection Work Plan This fall protection work plan shall be prepared by a “Competent Person” before work begins. The Competent Person shall be able to recognize all existing and potential hazards and have the authority to take prompt corrective action. This person shall have knowledge of fall protection equipment that includes manufacturer’s recommendations, instructions for its proper use, inspection and maintenance. They shall also be trained and knowledgeable of the regulatory requirements regarding the erection, use inspection and maintenance for fall protection equipment and systems. This plan shall be posted and available on the jobsite. The competent person shall make changes necessary to this plan when conditions or hazards may change.

1. Identify work activities and all potential fall hazards: Click here to enter text. 2. Methods of Fall Arrest or Restraint:

☐ Full body harness with lanyard Click here to enter text. ☐ Tie off points capable of 5000 lb load Click here to enter text. ☐ Safety Lines and monitoring system Click here to enter text. ☐ Boom/Scissor Lift Click here to enter text. ☐ Scaffolding w/guardrails and toe boards Click here to enter text. ☐ Standard guard rails or cable Click here to enter text. ☐ Safety nets Click here to enter text. ☐ Other: Describe Click here to enter text.

3. Describe Procedures for assembly, inspection, maintenance and disassembly of fall protection system: Click here to enter text.

4. Overhead Protection:

☐ Hard Hats ☐ Warning Signs ☐ Toe Boards ☐ Screens ☐ Barricades ☐ Other: Describe Click here to enter text.

5. Describe procedures for handling, storage and securing of tools equipment and materials: Click here to enter text.

6. Overhead Protection: ☐ 911 ☐ Man Lift ☐ Forklift personnel work platform ☐ Crane with basket ☐ Life Line ☐ Other: Describe Click here to enter text.

7. Frequency of inspection: Describe Click here to enter text.

8. Describe employee training documentation: Click here to enter text.

______________________________ __________________ Competent Person Signature Date


CRANE AND HOIST SAFETY

Inspection, Maintenance, and Testing

All tests and inspections shall be conducted in accordance with the manufacturer’s recommendations.

Monthly Tests and Inspections

All in‐service cranes and hoists shall be inspected monthly and the results documented Defective cranes and hoists shall be locked and tagged "out of service" until all defects are

corrected. The inspector shall initiate corrective action by notifying the facility manager or building coordinator.

Annual Inspections

The fleet department shall schedule and supervise (or perform) annual preventive maintenance (PM)

and annual inspections of all cranes and hoists. The annual PM and inspection shall cover

Hoisting and lowering mechanisms Trolley travel or monorail travel Bridge travel Limit switches and locking and safety devices Structural members Bolts or rivets Sheaves and drums Parts such as pins, bearings, shafts, gears, rollers, locking devices, and clamping devices Brake system parts, linings, pawls, and ratchets Load, wind, and other indicators over their full range Gasoline, diesel, electric, or other power plants Chain‐drive sprockets Crane and hoist hooks Electrical apparatus such as controller contractors, limit switches, and push button stations Wire rope Hoist chains

Load Testing

Newly installed cranes and hoists shall be load tested at 125% of the rated capacity by designated personnel

Slings shall have appropriate test data when purchased. It is the responsibility of the purchaser to ensure that the appropriate test data are obtained and maintained

Re‐rated cranes and hoists shall be load tested to 125% of the new capacity if the new rating is greater than the previous rated capacity

Fixed cranes or hoists that have had major modifications or repair shall be load tested to 125% of the rated capacity


Cranes and hoists that have been overloaded shall be inspected prior to being returned to service

Personnel platforms, baskets, and rigging suspended from a crane or hoist hook shall be load tested initially, then re‐tested annually thereafter or at each new job site

All cranes and hoists with a capacity greater than 2722 kg (3 tons) should be load tested every four years to 125% of the rated capacity. Cranes and hoists with a lesser capacity should be load tested every eight years to 125% of the rated capacity

All mobile hoists shall be load tested at intervals to be determined by the manufacturer and state and federal regulations.

Records

The fleet department shall maintain records for all cranes, hoists


Crane Checklist Equipment: Click here to enter text.

Inspected By: Click here to enter text. Date: Click here to enter a date.

Description OK Needs correction

Date Corrected Corrected by

Control mechanisms (for maladjustment interfering with proper operation)

☐ ☐

Control mechanisms (for excessive wear of components and contamination by lubricants or other foreign matter)

☐ ☐

Operator aides (motion & load limiting devices & other safety devices for malfunction and inaccuracy of settings)

☐ ☐

Cords and lacing ☐ ☐

Hydraulic and pneumatic systems (with emphasis given to those which flex in normal operation of the crane)

☐ ☐

Hooks and latches for deformation (chemical damage, cracks and wear)

☐ ☐

Rope for proper spooling onto the drum(s) and sheave(s) (and rope reeving for compliance with crane manufacturer’s specifications)

☐ ☐

Electrical apparatus for malfunctioning (signs of excessive deterioration, dirt and moisture accumulation)

☐ ☐

Hydraulic system for proper oil level ☐ ☐

Tires for recommended inflation pressure (mobile cranes)

☐ ☐

Wedges and supports for looseness/dislocation (tower cranes)

☐ ☐

Braces and guys; anchor bolt base connections (tower cranes and derricks)

☐ ☐

Derrick mast fittings and connections (for compliance with manufacturer’s recommendations)

☐ ☐

Foundation or supports (for continued ability to sustain imposed loads)

☐ ☐

Braces supporting crane masts (towers) for safe condition; anchor bolt base connections for tightness or retention of preload; wedges and supports of climbing cranes for tightness and proper positioning

☐ ☐

Guys for proper tension ☐ ☐

Bolts, rivets, nuts and pins for tightness ☐ ☐Tires for damage or excessive wear ☐ ☐Crane structure and boom and job members (and their connections for absence of deformation, cracks, or corrosion)

☐ ☐


Description OK Needs correction

Date Corrected Corrected by

Proper tension (torque) of high strength (traction) bolts used in connections and at the slewing bearing

☐ ☐

Electrical apparatus for proper functioning (and absence of signs of excessive deterioration, dirt, and moisture accumulation)

☐ ☐

Hydraulic and pneumatic tanks, pumps, motors, valves, hoses, fittings, and tubing (for proper functioning and absence of damage, leaks, and excessive wear; hydraulic and pneumatic systems for proper fluid/air levels)

☐ ☐

All control mechanisms for adjustment (for proper operation, no excessive wear of components, and absence of contamination by lubricants or other foreign matter)

☐ ☐

Drive components (pins, bearings, wheels, shafts, gears, sheaves, drums, rollers, locking and clamping devices, sprockets, drive chains or belts, bumpers and stops for absence of wearing, cracks, corrosion or distortion)

☐ ☐

All crane function operating mechanisms (for proper operation, proper adjustment, and the absence of unusual sounds)

☐ ☐

Travel, steering, holding, braking and locking mechanisms (for proper functioning and absence of excessive wear or damage.)

☐ ☐

Brake and clutch system parts, linings, pawls, and ratchets (for absence of excessive wear)

☐ ☐

Wire rope (Visually inspect all running ropes; visually inspect all counterweight ropes and load trolley ropes, if provided. Visual inspections should concentrate on discovering gross damage)

a. Distortion / Corrosion of rope b. Number, distribution and type of visible broken

wires c. Broken or cut strands d. Core failure in rotation resistant ropes e. Reduction of rope diameter below nominal

diameter due to loss of core support f. Severely corroded or broken wires at end

connections

☐ ☐

Sheaves for absence of cracks in the flanges and spokes ☐ ☐

Rope for proper spooling onto drum(s) and sheave(s) and proper reeving

☐ ☐

Hooks and latches (for absence of deterioration, chemical damage, cracks and wear)

☐ ☐

Crane operator aids (safety devices) and indicating devices (for proper operation)

☐ ☐

Motion limiting devices (for proper operation with the crane unloaded)

☐ ☐

Load, boom angle, load or load moment indicating, wind, and other indicators (for proper operation and accuracies within the tolerances recommended by manufacturer)

☐ ☐

Safety and function labels for legibility and replacement ☐ ☐

Model Number Description Mileage

INSPECT AND/OR TEST THE FOLLOWING DAILY

OR AT THE BEGINNING OF EACH SHIFT:

[☐ ] 1. Operating and emergency controls. [☐ ] 2. Safety devices. [☐ ] 3. Personal protection devices. [☐ ] 4. Tires and wheels.

[☐ ] 5. Outriggers (if equipped) and other structures.

[☐ ] 6. Air, hydraulic, and fuel system(s) for leaks.

[☐ ] 7. Loose or missing parts

[☐ ] 8. Cables and wiring harness. [☐ ] 9. Placards, warning, control markings,

and operating Manual(s). [☐ ] 10. Guardrail system

[☐ ] 11. Engine oil level (if so equipped).

[☐ ] 12. Battery fluid level. [☐ ] 13. Hydraulic reservoir level.

[☐ ] 1. Coolant level (if so equipped).

[☐ ] 15. Other or by (manufacturer).

Walk-Around Inspection Before Use

Functional Test

Before Use

Work-site Hazard Assessment

Before & During Use

Proper Operation

Throughout Use

Proper Shutdown After Use

Step 1

Step 2

Step 3

Step 4

Step 5

5—Step Approach To Achieve…… Safe Elevated/Aerial Work Platform Operation

Is the unit safe visually?

Is the unit safe functionally?

Is the Work-site safe to operate in?

Am I operating safely & is this a safe place to operate from?

Is this unit shutdown safely?


WASHINGTON PATRIOT CONSTRUCTION, LLC


ELEVATED WORK PLATFORM I have read and understand the operating procedures and the shutdown procedures for the following elevated work platform: Brand Name: Click here to enter text. Size: Click here to enter text. Where Rented From: Click here to enter text. Date: Click here to enter text.

Operator’s Check List

INSPECT AND/OR TEST THE FOLLOWING DAILY OR AT THE BEGINNING OF EACH SHIFT: 1. Operating and emergency controls. 2. Safety devices. 3. Personal protection devices. 4. Tires and wheels. 5. Outriggers (if equipped) and other structures. 6. Air, hydraulic, and fuel system(s) for leaks. 7. Loose or missing parts. 8. Cables and wiring harness. 9. Placards, warning, control markings, and operating manual(s). 10. Guardrail system. 11. Engine oil level (if so equipped). 12. Battery fluid level. 13. Hydraulic reservoir level. 14. Coolant level (if so equipped). 15. Other or by (manufacturer).

WARNING

DO NOT OPERATE THIS EQUIPMENT WITHOUT PROPER AUTHORIZATION AND TRAINING. DEATH OR SERIOUS INJURY COULD RESULT FROM IMPROPER USE OF THIS EQUIPMENT!! TRAINED EMPLOYEES (Please Sign and Date):


Daily Inspection Checklist for All Driven Equipment Trucks/Equipment

Gas/Propane/Diesel Forklift This inspection should be conducted prior to each shift.

OK Comments KEY OFF Procedures

Inspect Vehicle ☐ Click here to enter text. • Overhead guard ☐ Click here to enter text. • Hydraulic cylinders ☐ Click here to enter text. • Mast assembly ☐ Click here to enter text. • Lift chains and rollers ☐ Click here to enter text. • Forks ☐ Click here to enter text. • Tires ☐ Click here to enter text. • LPG tank and locator pin ☐ Click here to enter text. • LPG tank hose ☐ Click here to enter text. • Gas gauge ☐ Click here to enter text.

Check engine oil level ☐ Click here to enter text. Examine the battery ☐ Click here to enter text. Check the hydraulic fluid level ☐ Click here to enter text. Check the engine coolant level ☐ Click here to enter text.

ROPS ☐ Click here to enter text. KEY ON Procedures

Check gauges ☐ Click here to enter text. • Oil pressure indicator lamp ☐ Click here to enter text. • Ammeter indicator lamp ☐ Click here to enter text. • Hour Meter ☐ Click here to enter text. • Water temperature gauge ☐ Click here to enter text.

Test the safety equipment • Steering ☐ Click here to enter text. • Brakes ☐ Click here to enter text. • Front, tail and brake lights ☐ Click here to enter text. • Horn ☐ Click here to enter text. • Seat Belts ☐ Click here to enter text.

Check the operation of the load-handling attachments ☐ Click here to enter text.

Check the transmission fluid level ☐ Click here to enter text.

Comments Click here to enter text.

If any item does not pass the inspection, turn off the PIT, tag it with a “Do Not Operate” tag, and report problems to your

supervisor.

Operator Click here to enter text. Equipment Type Click here to enter text. Model Click here to enter text. Date Click here to enter text.


EQUIPMENT OPERATOR TRAINING

Job Name: Click here to enter text. Job No. Click here to enter text.

I have been instructed and trained in safe operating procedures for:

Click here to enter text. on Click here to enter text.

(Type of Equipment) (Date)

____________________________ __________________________ ____________

(Employee Name) (Employee Signature) (Date)

____________________________ __________________________ ____________


____________________________ __________________________ ____________


____________________________ __________________________ ____________


____________________________ __________________________ ____________


____________________________ __________________________ ____________


____________________________ __________________________ ____________


___________________________ __________________________ ____________

(Instructor’s Name) (Instructor’s Signature) (Date)

Company Vehicle Accident Report

As a driver of a Washington Patriot Construction, LLC, vehicle you are responsible to fill out an accident

report regardless of how minor the damage. Forms are available at each facility and must be turned in

on the same day as the accident. Failure to report an accident can result in dismissal. Report all injuries

to your supervisor, regardless of severity.

Information to be taken at the scene of the accident:

Date of Accident: Click here to enter text.

Time of Accident


Location of Accident: Click here to enter text.

License # Click here to enter text. State Click here to enter text.

Make Click here to enter text. Model Click here to enter text. Year Click here to enter text.

Driver’s Name Click here to enter text.

State WA Zipcode 9xxxx Phone Number Click here to enter text.

Drivers License Number Click here to enter text. State WA.

Vehicle #2 License Number Click here to enter text. State WA.

Make Click here to enter text. Model Click here to enter text. Year Click here to enter text.

Registered Owner Click here to enter text.

Driver’s Name Click here to enter text.

Address Click here to enter text. City Click here to enter text.

State WA

Zip Code Click here to enter text. Phone Number Click here to enter text.

Driver’s License Number Click here to enter text. State WA.

Insurance Company Click here to enter text. Policy Number Click here to enter text.

Injuries Click here to enter text.

Names and addresses of vehicle occupants if applicable: Click here to enter text.

Description of accident: Click here to enter text.

Name and Addresses of witnesses: Click here to enter text.

Responding police agency (Officers name and badge number): Click here to enter text.

Driver’s Signature Date

DIAGRAM ACCIDENT BELOW

1. THE NAMES OF THE STREETS AND DIRECTION OF TRAVEL 2. THEPOSITIONS OF THE CARS BEFORE AND AFTER THE ACCIDENT 3. WIDTH OF STREETS 4. TRAFFIC CONTROLS WITH A CIRCLE 5. SHOW PEDESTRIANS WITH A “C” 6. PLEASE DISPLAY ANY OTHER VEHICLES OR IMPORTANT OBJECTS AND LABEL THEM 7. SHOW Washington Patriot Construction, LLC VEHICLE AS “CAR 1”, THE OTHER VEHICLE AS “CAR 2”

Date:

Name:

Begin Miles:End Miles:

In Cab ChecklistNext Oil Change At: (miles)Speedometer/TackometerMirrors/GlassWipersHeater/DefrostGaugesHornSeat BeltSteering Wheel PlayFire ExtinguisherTriangle ReflectorsDash Lights/hi/lo indicator

Out of cab check listLights/LensesHeadlights low

highMarker LampsTurn Signals left

rightBrake left

rightTail left

right4 Way/Hazard

EngineOil LevelCoolantBeltsFluid Leaks

Wheels/RimsAir Pressure Driver Front

Driver RearPass. FrontPass. Rear

Tread Depth Driver FrontDriver RearPass. FrontPass. Rear

Even Wear Driver FrontDriver RearPass. FrontPass. Rear

Loose Hug Nuts Driver FrontDriver RearPass. FrontPass. Rear

Cracks/Bent/Streaks Driver FrontDriver RearPass. FrontPass. Rear

Check all items on pre-trip. Use OK; if defect found use "X", use "NA" if not applicable. (Turn this inspection form in to Bruce Ternes or Dave Rutherford if unable to correct defect and place vehicle out of service until corrected)

This form is to be used prior to any utilization of the one ton truck - no exceptions

WA Patriot 1-Ton Inspection Compete before leaving shop area



Daily Scaffold Inspection

On all Washington Patriot Construction, LLC projects, all scaffolding and related operation in direct relationship to the proper use and erection of scaffolding will be reviewed on a daily basis. These inspections should be reviewed before the arrival of the day’s work crew. Any corrections that need to be done and signatures of the competent person in review shall be recorded on the signature and comment sheet. Below is a list of some of the items that should be checked. There may be other items not listed below that may need to be reviewed. Please review scaffolding regulation from the L & I manual for any questions.

1. Accessories – Items other than frames and bracing 2. Adjustment screws – Device to level and plumb scaffolding 3. Base plates – Devise to distribute leg load 4. Climbing ladder – Ladder directly attached to scaffold 5. Coupling pin – Attachment to connect lift or ties together 6. Cross bracing – Members connecting frames or panels together 7. Guard rails – Rails secured to uprights along exposed side and ends 8. Horizontal diagonal bracing – Braces running horizontally between frames 9. Locking device – Device to secure cross brace to frames 10. Safe leg load – Load which can be directly imposed on frame leg 11. Scaffolding layout – Insure good practices for ground and any obstruction for installation 12. Side bracket cantilevered arm supported by scaffold frames 13. Sill or mud sill – A wood member (12 x 18) which transfers load to the ground 14. Toe boards – Barrier to secure objects from falling 15. Towers – Composite structure of frames, braces and accessories 16. Casters – Wheels suitable for scaffolding mobility 17. Rust – Flaking (if ¼” or bigger means items need to be removed) 18. Welds – Visual review during scaffold erection 19. Planking –approved 2 x 10 or 2 x 12 in good condition 20. Support of planking – 12” overlap and support of 6” minimum 21. Other


Daily Trench/Excavation Inspection Form

Project # Click here to enter text. Date

Click here to enter a date. Weather

Click here to enter text. Soil Type


Trench Depth

Click here to enter text. Trench Length Click here to enter text. Trench Width


Type of Protective System Click here to enter text. Foreman Click here to enter text.

Yes No N/A Excavation

☐ ☐ ☐ Excavation/Trench systems inspected daily by Competent Person before beginning work

☐ ☐ ☐ Competent Person has authority to take immediate corrective action when hazards are identified

☐ ☐ ☐ Surface encumbrances removed or supported

☐ ☐ ☐ Employees protected from loose rock or soil

☐ ☐ ☐ Hard hats and safety vest worn at all times by employees

☐ ☐ ☐ Spoils piles and material at least 2’ back from edge of excavation/trench

☐ ☐ ☐ Barriers provided at all excavations, wells, pits, shafts etc. that are remote

☐ ☐ ☐ Walkways and bridges with guardrails over trenches where employees must pass by

☐ ☐ ☐ Employee prohibited from walking or working under suspended loads

☐ ☐ ☐ Employees prohibited from working on faces of sloped or benched excavation above other employees

☐ ☐ ☐ Ladders used in trench boxes with at least 4 rungs showing Yes No N/A Utilities ☐ ☐ ☐ Utility companies contacted and all utilities located prior to work beginning

☐ ☐ ☐ Exact location of utilities marked near excavation

☐ ☐ ☐ Underground installations protected, supported or removed when excavation is open

☐ ☐ ☐ Overhead power lines identified and shielded shut off if necessary Yes No N/A Wet Conditions ☐ ☐ ☐ Precautions taken to protect employees from the accumulation of water

☐ ☐ ☐ Water removal equipment monitored by Competent Person

☐ ☐ ☐ Surface water controlled or diverted

☐ ☐ ☐ Inspection made after each rainstorm Yes No N/A Hazardous Atmospheres

☐ ☐ ☐ Atmosphere tested when there is a possibility of oxygen deficiency or a buildup of hazardous gasses

☐ ☐ ☐ Oxygen content is between 19.5% and 23.5%

☐ ☐ ☐ Ventilation provided to prevent flammable gas build of 10% of LEL (Lower Explosive Limit)

☐ ☐ ☐ Continuous testing to ensure that atmosphere remains safe

☐ ☐ ☐ Emergency response equipment is readily available where a potential of a hazardous atmosphere exists

☐ ☐ ☐ Employees trained in the use of personal protective equipment and emergency response equipment

☐ ☐ ☐ Safety harness and life line attended when employees enter a confined space Competent Person Signature________________________________Date____/____/________


DANGER

DO NOT CROSS THIS TAPE

IF YOU REQUIRE ACCESS CONTACT THE FOLLOWING

Company:

Contact Name:

Contact Number:

Work Performed:

Date


Daily Stilt Use Area Checklist Project: Click here to enter text. Contractor (if Applicable) Click here to enter text.

Described Area Where stilts will be used: Click here to enter text. Date: Click here to enter a date.

Have all Stilts been Inspected and repairs made as needed?

Yes ☐ No ☐

Have all employee complete the Stilt Use Training?

Yes ☐ No ☐

Identify all Hazards Checked Good Poor

What corrections have been made?

Access ☐ ☐ ☐ Click here to enter text.

Cords ☐ ☐ ☐ Click here to enter text.

Floor Conditions ☐ ☐ ☐ Click here to enter text.

Materials in area ☐ ☐ ☐ Click here to enter text.

Equipment in area ☐ ☐ ☐ Click here to enter text.

Live utilities/ Overhead hazards ☐ ☐ ☐ Click here to enter text.

Other ☐ ☐ ☐ Click here to enter text.

Conditions of Work area ☐ ☐ ☐ Click here to enter text.

Lighting Conditions Good Need improvement Poor

Lighting before Starting

Lighting during work

What Corrections have been made?

Correction of all hazards N/A Good Fix Repair Describe Corrections

Floor Covers ☐ ☐ ☐ Click here to enter text.

Floor Transitions ☐ ☐ ☐ Click here to enter text.

Floor Protection ☐ ☐ ☐ Click here to enter text.

Equipment in work path ☐ ☐ ☐ Click here to enter text.

Material in work area ☐ ☐ ☐ Click here to enter text.

Clear Access ☐ ☐ ☐ Click here to enter text.

Clear Floor Conditions ☐ ☐ ☐ Click here to enter text.

Other Reportable Conditions:

Supervisor inspecting area:

Sign Name Print Name

1

2

Sign Name Print Name

DO NOT START UNTIL CORRECTED

STOP UNTIL CORRECTED


3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30


Activity Hazard Analysis (AHA)

Activity/Work Task: Click here to enter text. Overall Risk Assessment Code (RAC) (Use highest code) Click here

Project Location: Click here to enter text. Risk Assessment Code (RAC) Matrix

Contract Number: Click here to enter text. Severity

Probability

Date Prepared: Click here to enter a date. Frequent Likely Occasional Seldom Unlikely

Prepared by (Name/Title): Click here to enter text. Catastrophic E E H H M

Critical E H H M L

Reviewed by (Name/Title): Click here to enter text. Marginal H M M L L

Negligible M L L L L Notes: (Field Notes, Review Comments, etc.) Click here to enter text.

Step 1: Review each “Hazard” with identified safety “Controls” and determine RAC (See above)

“Probability” is the likelihood to cause an incident, near miss, or accident and identified as: Frequent, Likely, Occasional, Seldom or Unlikely. RAC Chart “Severity” is the outcome/degree if an incident, near miss, or accident did occur and identified as: Catastrophic, Critical, Marginal, or Negligible

E = Extremely High Risk H = High Risk

Step 2: Identify the RAC (Probability/Severity) as E, H, M, or L for each “Hazard” on AHA. Annotate the overall highest RAC at the top of AHA.

M = Moderate Risk L = Low Risk

Job Steps Hazards Controls RAC Click here to enter text. Click here to enter text. Click here to enter text. Click

here to enter text.

Equipment to be Used Training Requirements/Competent or

Qualified Personnel name(s) Inspection Requirements

Click here to enter text. Click here to enter text. Click here to enter text.

Material to be Used Click here to enter text.

Inspection Requirements Click here to enter text.


ElectricalChecklist

Area Safety Check Yes No

☐ ☐ Are extension cords only used for temporary use?

☐ ☐ Are power cords free of splices, taps, and damaged insulation?

☐ ☐ Do all extension cords have ground pins in place?

☐ ☐ Are live electrical parts on tools, equipment, building wiring, and electrical panels enclosed to prevent contact?

☐ ☐ Do circuits become overloaded? If so why?

☐ ☐ Are breaker boxes clear and can they be accessed when needed?

☐ ☐ Are machines that have moisture (e.g. refrigerators, air conditioners) or used outdoors or industrial settings grounded?

☐ ☐ Do electrical cords and equipment used at wet locations have waterproof covers or seals to keep moisture out?


ExposureControlTrainingForm(Individual)

TRAINING OUTLINE

The trainer will provide copies of and/or verbally explain to the employee the following:

A copy of the regulations and an overview of the requirements of the regulation, including an explanation of its contents and the locations of the copies of the regulations at our company

An explanation of the Exposure Control Plan and where to obtain a copy

A general explanation of the epidemiology and symptoms of bloodborne diseases

An explanation of the modes of transportation of bloodborne pathogens

An explanation of the appropriate methods of recognizing tasks and other activities that may involve exposure to blood and other potentially infectious materials

An explanation of the use and limitations of methods that will prevent or reduce exposure including appropriate, work practices, and personal protective equipment.

Information of the types, proper uses, location, removal, handling, decontamination, and disposal of personal protective equipment

An explanation of the basis for selection of personal protective equipment.

Information on the hepatitis B vaccine, including information on its efficacy, safety, method of administration, and the benefits of being vaccinated.

Information on the appropriate actions to take and persons to contact in an emergency involving blood or other potentially infectious materials.

An explanation of the procedure to follow if an exposure incident occurs, including the method of reporting, and medical follow‐up that will be made available.

Information on the post‐exposure evaluation and the follow‐up the employer is required to provide for the employee following an incident.

An opportunity for interactive questions and answers with the trainer.

_______________________________ ______________________________ Signature of Trainer Date of Training _______________________________ ______________________________ Signature of Employee Date of Training


Employee Injury Report L&I Claim

Employee Name: Click here to enter text. Craft: Click here to enter text.

Project Name: Click here to enter text. Project Number: Click here to enter text.

Supervisor Name: Click here to enter text. Date of Injury :

Click here to enter a date. Time of Injury


Vehicle Number: Click here to enter text. Trailer Number: Click here to enter text.


Task Being Performed at Time of Injury and Location: Click here to enter text.

Description of Injury: Click here to enter text.

How Did Injury Occur: Click here to enter text.

Why Did Injury Occur: Click here to enter text.

Medical Attention Required Yes ☐ No ☐

Name of Witnesses: 1. Click here to enter text.

2. Click here to enter text.

Contributing Factors of Injury: Click here to enter text.

Recommendations for Accident Prevention and Follow Up Actions Click here to enter text.

Employee Signature___________________________________Date______/______/_______

Reviewed By__________________________________________Date______/______/_______


Jobsite Incident Report 3rd Party/Non‐Vehicle

Date of Accident: Click here to enter text.

Time of Accident


Location of Accident: Click here to enter text.

Washington Patriot Construction, LLC Vehicle # Click here to enter text. License #

Click here to enter text. State


Make Click here to enter text. Model

Click here to enter text. Year Click here to enter text.


Supervisor Name: Click here to enter text. Incident Date :

Click here to enter a date. Incident Time:



Location of Incident: Click here to enter text.

Task Being Performed at Time of Incident: Click here to enter text.

Incident Resulted in: ☐ Injury ☐ Property Damage ☐ Fatality ☐ Vehicle Damage

Name of Witnesses: Click here to enter text.

How Did Incident Occur: Click here to enter text.

Why Did Incident Occur: Click here to enter text.

What contributed to the Incident: Click here to enter text.

Recommendations for Prevention and Follow up Consultation: Click here to enter text.

Employees Signature___________________________________Date____________________

Reviewed By__________________________________________Date___________________


Jobsite Incident Report 3rd Party

Employee Name: Click here to enter text. Craft: Click here to enter text.


Supervisor Name: Click here to enter text. Incident Date :

Click here to enter a date. Incident Time:



Location of Incident: Click here to enter text.

Task Being Performed at Time of Incident: Click here to enter text.

Incident Resulted in: ☐ Injury ☐ Property Damage ☐ Fatality ☐ Vehicle Damage

Name of Witnesses: Click here to enter text.

How Did Incident Occur: Click here to enter text.

Why Did Incident Occur: Click here to enter text.

What contributed to the Incident: Click here to enter text.

Recommendations for Prevention and Follow up Consultation: Click here to enter text.

Employees Signature___________________________________Date____________________

Reviewed By__________________________________________Date___________________


Supervisor’s Accident/Injury Investigation Report

Date: Click here to enter a date. Time:

Click here to enter text. Day of Week: Monday


Project Address: Click here to enter text.

Employee Name: Click here to enter text. Craft:Click here to enter text.

Part of body injured: Click here to enter text.

Exact location of accident/injury (attach map or drawing if necessary): Click here to enter text.

Describe the work task being completed at the time of accident/injury: Click here to enter text.

At what step of the work task (described above) did the accident/injury occur: Click here to enter text.

When was the last time the injured person perform this task: Click here to enter text.

How did this accident happen: Click here to enter text.

What did the injured employee do OR not do that may have contributed to this injury: Were there other contributing factors (people, processes, or equipment failure)?

☐Yes ☐No

Are there written safety rules or regulations for this work task? ☐Yes ☐No

Were safety rules or regulations being followed? ☐Yes ☐No

Has the injured person received training for these safety rules or regulations?

☐Yes ☐No

When did the injured person last attend a safety meeting: Click here to enter text. When did the injured person last receive specific safety training for this work task: Click here to enter text.

Name of witnesses (attach statements and interviews): Click here to enter text.


Name of immediate supervisor: Click here to enter text. Supervisor Signature Date

Corrective Action Plan What type of corrective actions (recommendations) have you taken or do you plan to take to prevent this type of injury/accident from reoccurring: Click here to enter text.

Supervisor Signature Date


Written Safety Warning

Employee Name: Click here to enter text. Date: Click here to select date.

Department: Click here to enter text.

Supervisor Name: Click here to enter text. Type of Warning: ☐ Verbal Warning ☐ Written Warning ☐ Suspension Without Pay ☐ Dismissal 1. Statement of the problem: Click here to enter text. (Include specific violation of rules, safety requirements, company practices or unsatisfactory performance)

2. Prior discussion or warning on this subject): Click here to enter text. (Include dates of prior warnings, both oral and written)

3. What is the company policy on this subject: Click here to enter text.

4. Summary of corrective action to be taken: Click here to enter text. (include timeline for improvement and plans for follow up)

5. Employee comments Click here to enter text. (Employee does not have to agree with the Company’s actions, but the Employee is nevertheless required to follow the corrective action set forth herein) Employee Signature Date

Supervisor Signature Date


Management Near Miss Investigation

Name of Person Completing Report: Click here to enter text.

Position/Title: Click here to enter text.

Is the person completing report trained in accident investigations Select Yes or No Was Equipment involved Select Yes or No

Type of Equipment Click here to enter text.

Is there an inspector for equipment Select Yes or No

Date of last inspection performed Click here to enter a date.

Have similar accident/incidents occurred Select Yes or No

Did the incident involve the same individual Select Yes or No

Same location Select Yes or No OR

Was the scene visited during the investigation Select Yes or No

Date of Accident: Click here to enter a date. Time of Accident Click here to enter text. Are there pictures available Select Yes or No

If no, reason for not visiting Click here to enter text.

Root Cause Analysis Unsafe Act (Primary) Choose an item.

If other specify: Click here to enter text.

Detailed explanation of selected unsafe act Click here to enter text.

Why was act committed Unsafe Condition (Primary) Choose an item.

If other specify: Click here to enter text.

Why did condition exist: Click here to enter text.

Contributory Factors (if any): Click here to enter text.

Immediate action to be taken to prevent recurrence: Click here to enter text.

Long range action to be taken: Click here to enter text.

What additional assistance is needed to prevent recurrence: Click here to enter text.

safety checklist and forms

Documents