Appendix 2 Forms
DAILY EXCAVATION CHECKLIST Client Project Name Project Location Job Number Excavation Size (Length x Width x Depth) Protective System Used Activities In Excavation Competent Person Date Approx. Temp. Approx. Wind Dir. Safety Rep Soil Classification Excavation > 4 feet deep? Yes No If YES, complete a Confined Space Permit BEFORE any person enters the excavation. NOTE: Trenches over 4 feet in depth are considered excavations. Any item below marked NO must be corrected or controlled BEFORE any person enters the excavation. YES NO N/A POTENTIAL HAZARD GENERAL Employees protected from cave-ins & loose rock/soil that could roll into the excavation? Spoils, materials & equipment set back at least 4 feet from the edge of the excavation? Engineering designs for shoring &/or manufacturer's design specifications for trench box on site? Adequate signs posted and barricades provided? Training (toolbox meeting) conducted w/ employees prior to entering excavation? UTILITIES Utility company contacted & given 24 hours notice &/or utilities already located & marked? Overhead lines located, noted and reviewed with the operator? Utility locations reviewed with the operator & precautions taken to protect against contact? Utilities crossing the excavation supported, and protected from falling materials? Underground installations protected, supported or removed when excavation is open?
WET CONDITIONS Precautions taken to protect employees from water accumulation (continuous dewatering)? Surface water or runoff diverted / controlled to prevent accumulation in the excavation? Inspection made after every rainstorm or other hazard increasing occurrence? HAZARDOUS ATMOSPHERES Air in the excavation tested for oxygen deficiency, combustibles, other contaminants? Atmospheric hazards present? Ventilation used in hazardous atmospheres? Emergency equipment available where hazardous atmospheres could or do exist? Safety harness and lifeline used? Supplied air necessary (if yes, contact safety department)? ENTRY & EXIT Exit (i.e. ladder, sloped wall) no further than 25 feet from ANY employee? Ladders secured and extend 3 feet above the edge of the trench? Wood ramps constructed of uniform material thickness and cleated together at the bottom? Employees protected from cave-ins when entering or exiting the excavation? KEEP 1 COPY OF EACH DAILY EXCAVATION CHECKLIST ON SITE FOR THE PROJECT DURATION
Lockout Procedure Lockout Procedure for: (Name or identification of equipment). Purpose This procedure establishes the minimum requirements for the lockout of energy isolating devices whenever maintenance or servicing is done on machines or equipment. It shall be used to ensure that the machine or equipment is stopped, isolated from all potentially hazardous energy sources and locked out before employees perform any servicing or maintenance where the unexpected energization or start-up of the machine or equipment or release of stored energy could cause injury. Compliance With This Program All employees are required to comply with the restrictions and limitations imposed upon them during the use of lockout. The authorized employees are required to perform the lockout in accordance with this procedure. All employees, upon observing a machine or piece of equipment which is locked out to perform servicing or maintenance shall not attempt to start, energize, or use that machine or equipment. Procedures (1) Notify all affected employees that servicing or maintenance is required on a machine or equipment and that the machine or equipment must be shut down and locked out to perform the servicing or maintenance. Name(s)/Job Title(s) of affected employees and how to notify. (2) The authorized employee shall refer to the company procedure to identify the type and magnitude of the energy that the machine or equipment utilizes, shall understand the hazards of the energy, and shall know the methods to control the energy. Type(s) and magnitude(s) of energy, its hazards and the methods to control the energy. (3) If the machine or equipment is operating, shut it down by the normal stopping procedure (depress the stop button, open switch, close valve, etc.). Type(s) and location(s) of machine or equipment operating controls.
(4) De-activate the energy isolating device(s) so that the machine or equipment is isolated from the energy source(s). Type(s) and location(s) of energy isolating devices. (5) Lock out the energy isolating device(s) with assigned individual lock(s). (6) Stored or residual energy (such as that in capacitors, springs, elevated machine members, rotating flywheels, hydraulic systems, and air, gas, steam, or water pressure, etc.) must be dissipated or restrained by methods such as grounding, repositioning, blocking, bleeding down, etc. Type(s) of stored energy - methods to dissipate or restrain. (7) Ensure that the equipment is disconnected from the energy source(s) by first checking that no personnel are exposed, then verify the isolation of the equipment by operating the push button or other normal operating control(s) or by testing to make certain the equipment will not operate. Caution: Return operating control(s) to neutral or "off" position after verifying the isolation of the equipment. Method of verifying the isolation of the equipment. (8) The machine or equipment is now locked out. "Restoring Equipment to Service." When the servicing or maintenance is completed and the machine or equipment is ready to return to normal operating condition, the following steps shall be taken. (1) Check the machine or equipment and the immediate area around the machine to ensure that nonessential items have been removed and that the machine or equipment components are operationally intact. (2) Check the work area to ensure that all employees have been safely positioned or removed from the area. (3) Verify that the controls are in neutral.
(4) Remove the lockout devices and reenergize the machine or equipment. Note: The removal of some forms of blocking may require reenergization of of the machine before safe removal. (5) Notify affected employees that the servicing or maintenance is completed and the machine or equipment is ready for used. NOTES OR COMMENTS:
CONFINED SPACES Are confined spaces throughly emptied of any corrosive or hazardous substances, such as acids or caustics, before entry? Are all lines to a confined space, containing inert, toxic, flammable, or corrosive materials valved off and blanked or disconnected and separated before entry? Are all impellers, agitators, or other moving parts and equipment inside confined spaces locked-out if they present a hazard? Is either natural or mechanical ventilation provided prior to confined space entry? Are appropriate atmospheric tests performed to check for oxygen deficiency, toxic substances and explosive concentrations in the confined space before entry? Is adequate illumination provided for the work to be performed in the confined space? Is the atmosphere inside the confined space frequently tested or continuously monitored during conduct of work? Is there an assigned safety standby employee outside of the confined space, when required, whose sole responsibility is to watch the work in process, sound an alarm if necessary, and render assistance? Is the standby employee appropriately trained and equipped to handle and emergency? Is the standby employee or other employees prohibited from entering the confined space without lifelines and respiratory equipment if there is any question as to the cause of an emergency? Is approved respiratory equipment required if the atmosphere inside the confined space cannot be made acceptable?
Is all portable electrical equipment used inside confined spaces either grounded and insulated, or equipped with ground fault protection? Before gas welding or burning is started in a confined space, are hoses checked for leaks, compressed gas bottles forbidden inside of the confined space, torches lighted only outside of the confined area and the confined area tested for an explosive atmosphere each time before a lighted torch is to be taken into the confined space? If employees will be using oxygen-consuming equipment-such as salamanders, torches, and furnaces, in a confined space-is sufficient air provided to assure combustion without reducing the oxygen concentration of the atmosphere below 19.5 percent by volume? Whenever combustion-type equipment is used in a confined space, are provisions made to ensure the exhaust gases are vented outside of the enclosure? Is each confined space checked for decaying vegetation or animal matter which may produce methane? Is the confined space checked for possible industrial waste which could contain toxic properties? If the confined space is below the ground and near areas of motor vehicles will be operating, is it possible for vehicle exhaust or carbon monoxide to enter the space?
SCAFFOLDING INSPECTION REPORT Client: Job No: Date: Scaffold Location: Time: : AM/PM Inspected by: NOTE: Scaffold shall not be used unless these items are found satisfactory. SECTION 1. Yes No Comments 1. Base plates/screw jacks on firm contact with sills/deck to prevent settling. 2. Scaffold appears to be level and verticals are plumb. 3. Safe, proper access and egress provided to all work platforms. 4. All platforms properly/tightly planked and secured from movement. 5. All toeboards secured in place. 6. All guardrails and midrails in place. 7. Are vertical legs rigidly braced to prevent swaying. 8. Scaffold anchored or equalized (4 to 1) to prevent movement (butts/ties installed). 9. No energized, unprotected electrical is within 12 feet of the scaffold. 10. Has the scaffold been tagged and has not been altered.
SECTION 2. Yes No Comments 1. Scaffold planks construction grade lumber and in sound condition. 2. Are all planking and toeboards in place and secured. 3. All guardrails and midrails in place and secured. 4. All tools and material raised and lowered to locations just carried by employees. 5. Working platforms clear of all loose tools, cords, material, etc. 6. Exit ways and ladders clear and unobstructed. 7. Stair and planks free of debris or slippery surface. 8. Work being performed on the scaffold in accordance with load ratings. 9. Have barricades been installed, scaffold tags been placed properly. Inspector: Print Supervisor: Print Sign Sign Scaffold Size: NOTES:
RESPIRATOR LOG SHEET DAILY INSPECTION DAILY WASH & CLEAN DATE FILTER REPLACED SANITIZE WEEKLY (Indicate date) INITIALS REMARKS &/OR COMMENTS NOTE: Please give this log sheet to Purchasing after it is completely filled.
JOB HAZARD ANALYSIS (JHA) LOCATION: ANALYSIS DONE BY: DATE: JOB #: ANALYZER S SIGNATURE: Complete this form by: 1) Identify the Task you are going to perform in the TASK column. 2) List the Potential Hazards for the task in the POTENTIAL HAZARDS column. 3) List the Safe Job Procedure and PPE to eliminate the Hazard in the SAFE WORK PROCEDURES column. 4) Identify who will mitigate the Potential Hazards in the ACTION BY column. 5) Identify the Completion Date of the mitigation in the COMPLETION DATE column. TASK POTENTIAL HAZARDS SAFE WORK PRACTICES ACTION BY COMPLETION DATE
HAYWARD ELECTRIC ENERGIZED WORK JOB HAZARD ANALYSIS (JHA) The undersigned have read, or have had read to them, and understand the general and special precautions to be observed and the protective equipment requirements of Hayward Electric s specific procedures for working on energized equipment and/or permit(s) issued to them on numbered covering work at the scope of which is: Additionally, all of the undersigned have discussed the specific job they are to perform with the emphasis on the hazards attendant to its performance, the means of abating or controlling the hazards identified, possible conflicts with other jobs in the immediate area which could result in putting them at risk and a general awareness of conditions in the area in which they are working. THE DISCUSSION HAS BE ON THE REVERSE SIDE HEREOF, REDUCED TO ENERGIZED WORK JOB HAZARD ANALYSIS. Crew Members: FOREMAN DATE
HAYWARD ELECTRIC COMPANY ACCIDENT INVESTIGATION REPORT Report Date: Accident Location: Incident Date: Incident Time: AM/PM Vehicle Accident Employee Injury Employee Illness EMPLOYEE: Name: Position: Home Address: Home Telephone: ( ) Age: Sex: Male Female Social Security Number: - - Use Additional Pages as Necessary for Complete Information!. Witnesses: NAME ADDRESS PHONE
2. Complete Description of Accident (Attach separate drawing(s) and/or diagram(s) as appropriate): 3. Individual(s) injured, other than EMPLOYEE named above: 4. Description of injury to EMPLOYEE: 5. Property & Equipment damaged in the accident, including the nature of the damage: 6. Describe all personal protective equipment used, and all necessary safety equipment that was in place: 7. Were there any perceived actual or possible safety violations in the area of the accident?: 8. Describe events and conditions immediately before the accident:
9. Describe events and conditions that did or may have caused or contributed to the accident: 10. Are these still in existence: Yes No Comment: 11. Were any unsafe actions performed by the EMPLOYEE or by others, or were any safety roles violated in a manner that caused or contributed to the accident?: 12. Describe steps taken to secure the area, or otherwise prevent similar occurrence: 13. Describe measures to be taken to prevent reoccurrence:
14. Medical care was provided: On-site of the accident. By: Emergency Room: Hospital: Doctor s Office: Describe care provided: 15. Did EMPLOYEE report to the work the next scheduled day: Yes No 16. Other relevant information: Prepared By: Name: Title: Date:
BEFORE STARTING HOT WORK, REVIEW ALL SAFETY PRECAUTIONS. CAN THIS JOB BE AVOIDED OR IS THERE A SAFER WAY? THIS PERMIT IS REQUIRED FOR TEMPORARY OPERATIONS INVOLVING OPEN FLAME OR PRODUCING HEAT AND/OR SPARKS: WELDING, CUTTING, BRAZING, GRINDING, SOLDERING, OR USING A TORCH TO THAW PIPING OR HEAT MATERIAL. THE PERMIT APPLIES ONLY TO THIS JOB, IN THE AREA SPECIFIED, DURING THE TIME AND DATE NOTED. INSTRUCTIONS PRECAUTION & SAFEGUARD CHECKLIST SUPERVISOR: Fire extinguisher available. 1. Complete PRECAUTION & SAFEGUARD Hot work equipment in good repair. CHECKLIST at right. Hazardous energy locked out. 2. Complete this permit form and issue to person performing hot work procedure. REQUIREMENTS WITHIN 35 FT OF WORK: 3. Verify FIRE WATCH. Flammable liquids and combustible material removed from area. HOT WORK PERFORMED BY: Company Employee Contractor: WORK ORDER NO.: LOCATION/BLDG/ROOM/FLOOR: Floors swept and overhead structure cleaned of dust, lint and debris. Fire-resistive covers and metal shields provided as needed. All floor and wall openings covered and or protected. WALLS/CEILINGS: remove combustibles away from opposite side or adjacent structures. WORK TO BE PERFORMED: PERSON PERFORMING WORK/DEPT.: WORK ON ENCLOSED/CONFINED EQUIP: Adequate ventilation is provided. Atmosphere checked with gas detector. Purge any flammable vapors. Confined Space Permit obtained, if required. FIRE WATCH: SUPERVISOR SIGNATURE: (obtain prior to job) I have verified that the above location has been inspected and The required PRECAUTIONS & SAFEGUARDS have been taken. Permission is authorized only for the work described above. Trained and equipped Fire Watch provided during operations and at least 30 minutes after. SPECIAL INSTRUCTIONS: PERMIT DATE: TIME: EXPIRES FINAL CHECK DATE: TIME: WORK DATE: TIME: COMPLETE EMPLOYEE SIGNATURE: SUPERVISOR SIGNATURE: