Contractor_Safety_-_Activity_Checklist.pdf

ENVIRONMENT/SITE SPECIFIC HAZARDS CURRENTLY EXCLUDED

Instructions:

The Safety Checklist is a tool for Contractors to help identify the tasks, hazards, and controls, based upon their scope of work, and to properly align them with California Occupational Safety and Health Administration’s requirements.

The Safety Checklist is intended to be filled out by general contractors to incorporate their work and the work of all their lower tier subcontractors. Filling out the Safety Checklist helps determine if the General Contractor and its Subcontractor(s) is taking into account expected hazards and controls based upon the scope of work. This information should ultimately help all Contractors with completing their Job Hazard Analysis (JHA) documents.

DATE:

General Contractor Company Name and Phone No.:

Project Title:

Project Start Date:

Project Location:

Contractor Safety – Activity Checklist

ENVIRONMENT/SITE HAZARDS CURRENTLY EXCLUDED

1. Site Safety Representative:

Provide the name(s) of those person(s) onsite who are capable of identifying existing and predictable hazards in the surrounding or working conditions which are unsanitary, hazardous, or dangerous to employees, and who has the authorization to take prompt corrective measures to eliminate them. The Contractor shall ensure that their Site Safety Representative(s) listed have been appropriately trained as applicable.

Site Safety Representative:

Site Safety Representative:

2. Cal/OSHA Competent & Qualified Person(s):

Provide the name(s) of those persons onsite who by possession of a recognized degree, certification, or professional standing, or who by extensive knowledge, training, and experience, has successfully demonstrated their ability to solve or resolve problems relating to the subject matter, the work, or the project. The Contractor shall ensure that each qualified and competent person listed has been trained in the following areas as applicable:

Asbestos Competent Person:

Lead Competent Person:

Crane Competent Person:

Confined Space Entry Supervisor:

Demolition Competent Person:

Electrical LOTO Qualified Person(s):

Energized Electrical Qualified Electrical Worker(s):

Excavation & Trenching Competent Person:

Fall Protection Competent Person:

Fall Protection Qualified Person:

Ladder Competent Person:

Scaffold Competent Person:

Steel Erection Competent Person:

3. Personal Protective Equipment:

Safety glasses, hard hats and work boots are required 100% of the time while working within the designated construction area on any construction or facilities maintenance project. High visibility safety vests are required on most construction sites.

Additional task-specific PPE will be required based on the answers below:

3a Identify the PPE that you will require based on the hazards of the tasks to be performed:

Full Face Shields Chemical Splash Goggles Welders Hood and Goggles, Leathers Gloves Steel Toed Boots, Work Gloves Ear plugs Or Ear Muffs Other (describe)

YES

YES

YES

YES

YES

YES

YES

NO

NO

NO

NO

NO

NO

3a Identify Specialty PPE Fall Protection: Active or passive fall protection is required any time the worker is either above 4 feet (maintenance work) or above 6 feet (construction work).

Subcontractor will submit the following documentation for fall protection:

- Fall Protection Work Plan

- Training Records

NA

YES

YES

NO

NO

Electrical PPE:

Identify electrical PPE to be worn.

Head protection Eye & Face Rubber-Insulating Gloves Rubber-Insulating Sleeves Leather Protectors Dielectric Footwear Flame Resistant (FR) Clothing FR Face Protection Products FR Outerwear (Raingear, etc.)

NA

YES

YES

YES

YES

YES

YES

YES

YES

YES

NO

NO

NO

NO

NO

NO

NO

NO

NO

Respiratory Protection:

Subcontractor will submit the following documentation for respirator use:

- Respiratory Protection Plan:

- Medical Surveillance Release (remove/blacken out personal information):

- Quantitative Fit Test Records:

- Qualitative Fit Test Records:

- Training Records:

NA

YES

YES

YES

YES

YES

NO

NO

NO

NO

NO

4. Hand and Power Tools NA Will the work involve the use of electrically powered tools? YES NO

Will the work involve the use of pneumatically powered tools? YES NO

Will the work performed on this project involve the use of powder-actuated tools?

Contractor will submit the following items for Powder Actuated tools:

- Training Records:

YES

YES

NO

NO

5. Ground & Surface Penetrations NA Will the work scope require you to cut into, chip into, drill into, or make any other penetrations into walls, ceilings or floors deeper than 1 5/8”?

YES NO

Will the work scope require you to excavate, trench, dig, or otherwise penetrate into the ground (including use of stakes or poles) deeper then 1 5/8”?

YES NO

Will the work scope require you to penetrate into any concrete surface at any depth?

YES NO

Have building surfaces or structures to be penetrated been evaluated for lead and asbestos?

YES NO

6. Excavation and Trenching NA Will this work scope involve any excavation up to 5 feet deep? YES NO Will this work scope involve any excavation deeper than 5 feet? YES NO Will this work scope involve sanitary sewer line repair or replacement? YES NO

Will this work scope involve storm sewer line repair or replacement? YES NO Contractor will submit the following items for Excavation and Trenching:

- JHA detailing Shoring Plan

- Training Records

YES

YES

NO

NO

7. Demolition NA The Contractor has signed off on the Isolation Plan: Electrical, Gas, Water, Steam, or other Utilities?

YES NO

Contractor will submit the following items for Demolition Plan:

- An Isolation Plan along with a SOP for startup. YES NO

8. Traffic & Pedestrian Control NA Will this work scope require ANY traffic or pedestrian disruptions?

Blocking or partially blocking any roadway, walkway or driveway…?

YES NO

Contractor will submit the following items:

- Traffic & Pedestrian Plan

- Training Records for Flaggers

YES

YES

NO

NO

9. Hazardous Energy Control (Lock out Tag out) NA Will you be doing any electrical work?

If “YES”, your company must submit a copy of your electrical safety program outlining how you meet the requirements of NFPA 70E.

YES NO

Electrical work includes:

- Working within 42 inches of an energized electrical part (for example;

working inside a VFD with an unshielded line side or working within 42 inches of an energized crane bus bar).

- Testing for zero energy

- Troubleshooting, and inspecting

- Making changes to the facility electrical system (for example; replacing breakers or wiring).

Will your work involve working on non-electrical systems that contain hazardous energy?

[ ] Mechanical [ ] Pneumatic [ ] Chemical [ ] Thermal [ ] Hydraulic [ ] Water [ ] Steam [ ] Gas

YES NO

Will your work include service, maintenance, or modification of equipment in which the unexpected energization or start-up of the equipment, or the release of stored energy, could cause injury to people or damage to equipment?

YES NO

Will your work require you to overlock onto an existing LOTO lock to protect from hazardous energy?

YES NO

Are you removing or opening any electrical equipment covers of electrical equipment? For example boxes, panels, disconnect switches, etc.

YES NO

Are you doing any demolition work that will require the removal of electrical equipment, walls, partitions, building structures, piping systems, ducts, etc.?

YES NO

Are you working in the travel path of a crane, hoists, or other equipment that present crush or pinch hazards?

YES NO

Will your work require installing, repairing or modifying rotating equipment?

YES NO

Will your work require the potential exposure to more than 250 volts? YES NO

NOTE: A LOTO Permit is not required when the following requirements are met:

- The equipment is electrically connected by a cord and plug.

- Unplugging the equipment removes all forms of hazardous energy.

- The plug will remain constantly under the exclusive control of the servicing technician for the duration of the installation, servicing and maintenance process.

10. Elevated Work Surfaces (aerial / scissors lifts, scaffolds or ladders) NA Identify what will be used on this project below:

Elevated Work Platforms Aerial Lift

Articulating Boom Lift Scissor Lift Man-Lift Other (identify)

YES

YES

YES

YES

YES

NO

NO

NO

NO

NO

- Training Records for each person operating lift. YES NO Scaffolding Tubular & Coupler Scaffolding Rolling Scaffold Mobile Scaffold Mason/Bricklayers Scaffold Other (describe):

YES

YES

YES

YES

YES

NO

NO

NO

NO

NO

- Training records for each person erecting and disassembling scaffold.

- A written fall protection plan (such as the LBNL fall protection matrix)

- Training records for users of fall protection

- Training records for scaffold users

YES

YES

YES

YES

NO

NO

NO

NO

Identify ladders that will be used on this project below:

6’ or smaller A-Frame or Platform Ladder YES NO 6’ to 12’ A-Frame or Platform Ladder. YES NO 12’ or greater A-Frame or Platform Ladder. YES NO Extension Ladder less than 24’ YES NO Extension Ladder over 24’ YES NO

11. Cranes & Heavy Equipment NA Identify cranes or heavy equipment that will be used on this project below:

Backhoe Front End Loader Excavator Crane Under 3 Tons Crane Over 3 Tons Forklift Other (identify)

YES

YES

YES

YES

YES

YES

YES

NO

NO

NO

NO

NO

NO

NO

Contractor will submit the following items for aerial and platform lifts:

Contractor will submit the following items for scaffold use:

Contractor will submit the following items for crane or heavy equipment:

- Crane current annual inspection certification:

- Crane quadrennial proof load test certification:

- Crane operator’s license:

- Backhoe, Front End Loader, Excavator proof of competency

- Forklift operator certification/license:

YES

YES

YES

YES

YES

NO

NO

NO

NO

NO

12. Fire Protection & Prevention NA Will work include the use of open flames such as torches, welders, grinders, tar pots or any other tool or process/procedure that could cause sparks or open flames?

YES NO

Will work be performed near combustible storage containers? YES NO

Will there be on-site refueling of equipment? YES NO

Has a Fire Watch been training in the use of fire extinguisher and emergency procedures for the work being performed?

YES NO

Contractor will submit for hot work activities: YES NO

13. Steel Erection and Assembly NA Is steel erection part of this work scope? YES NO

Contractor will submit the following items for Steel Erection and Assembly:

- Site-Specific Erection plan

- Fall protection work plan (per ANSI/ASSE Z359)

YES

YES

NO

NO

14. Hazardous Substances or Materials NA Certain existing building components or materials that may be impacted by the work of this project are known or presumed to contain hazardous materials including, but not limited to, asbestos and lead. Comply with the applicable abatement sections and safety requirements of the contract documents. Should the contractor(s) or subcontractor(s) determine or believe that any building component or material, not already noted as containing a hazardous material, contains asbestos, lead, or other hazardous material, they shall notify the County of Orange immediately. Common building materials that contain asbestos include floor tile and mastic, sheetrock and taping compound, pipe insulation, fire doors, and transite. Paint surfaces and settled dust commonly contain lead.

The Contractor is required to perform their own exposure assessments for hazardous materials.

Will the work involve the use of any chemicals, such as paints, solvents, adhesives, epoxy coatings, fuels or other hazardous materials?

YES NO

Are all personnel using these materials trained in safe handling? YES NO

Will there be an emergency eyewash and shower in the immediate work area at a location that can be reached by a blinded worker in an uncomplicated and unimpeded path within 10 seconds travel time (approximately 50 feet)?

If “NO”, a portable eyewash station, capable of providing 15 minutes of continuous water flow, shall be provided (handheld squeeze bottle type is not allowed) that meets the same access requirement listed above?

YES NO

Will employees be potentially exposed to airborne concentrations of hazardous gas, fume, dust or mist?

YES NO

Will SDS(s) be available to the workers onsite? YES NO

Will respirators be required? YES NO

Describe the type of respiratory protection to be used:

15. Permit-Required Confined Space Entry NA Will the scope of your work require you to be working in a confined space where physical or atmospheric hazards (i.e. Flammable or Toxic) may be present?

YES NO

Contractor will submit the following items for Confined Space Entry:

- Contractor’s Confined Space Program

- Example Alternate Method, Reclassification, and Permit-required Confined

Space Entry Permits

- Training records

YES

YES

YES

NO

NO

NO

16. Welding / Hot Cutting NA Will the work involve welding/cutting steel at painted surface? YES NO

Will the work involve welding/cutting stainless steel? YES NO

Contractor will submit the following items for welding or hot cutting on non-lead containing surfaces (new steel construction):

- Respiratory Protection Program

- Qualitatively fit tested ½ mask negative pressure respirator with fit test records

- Medical approval to wear respirators

- Respiratory protection training records

YES

YES

YES

YES

NO

NO

NO

NO

Contractor will submit the following items for welding or hot cutting on lead containing surfaces (where lead paint exists or has been abated):

- Respiratory Protection Program

- Quantitatively fit tested full face-piece Powered Air Purifying Respirator

(PAPR) and fit test records

- Medical approval to wear respirators

- Blood lead baseline sample results (excluding employee SSNs)

- Documentation that workers have received lead awareness training.

- Respiratory protection training records

YES

YES

YES

YES

YES

YES

YES

NO

NO

NO

NO

NO

NO

NO

Contractor will submit the following items for welding or hot cutting on stainless steel:

- Respiratory Protection Program

- Quantitatively fit tested, full face-piece negative pressure respirator and fit test records.

- Medical approval to wear respirators

- Documentation of hexavalent chromium training.

- Respiratory protection training records

YES

YES

YES

YES

YES

YES

NO

NO

NO

NO

17. Lead Paint NA Will the work involve sanding, grinding, scraping, brazing, cutting, welding, removing or otherwise disturbing painted surfaces in such a way that lead particles may become airborne?

YES NO

Contractor will submit the following items for lead paint removal:

- JHA for lead paint removal

- Site-Specific Lead Compliance Plan

- Respiratory Protection Program

- Company’s Lead Compliance Program

- Department of Public Health Lead Worker & Supervisor Training Certificates

- Full face-piece negative pressure respirator with quantitative fit test

- Medical approvals for respirator use

- Respiratory protection training records

YES

YES

YES

YES

YES

YES

YES

YES

NO

NO

NO

NO

NO

NO

NO

NO

18. Asbestos NA Will the work require asbestos removal or disturbance? YES NO

Will the work require a 10-day notification to (BAAQMD) for renovations involving RACM greater than or equal to 100 linear feet 100 sq. ft, or 35 cu ft prior to renovations?

YES NO

Contractor will submit the following items for asbestos removal:

- Site Specific Asbestos Compliance Plan

- JHA addressing asbestos hazards

- Respiratory Protection Program

- Subcontractor’s Asbestos Program

- Asbestos Worker Training Certificates

- Medical approvals & fit test records for respirator use

- Respiratory protection training records

YES

YES

YES

YES

YES

YES

YES

NO

NO

NO

NO

NO

NO

NO

19. Application of Paint and Other Coatings NA Does the scope of your work include sanding, scraping, grinding, washing or other prep activity?

YES NO

How will the paint / coating be applied?:

Sprayed Rolled Other (describe)

YES

YES

YES

NO

NO

NO

Contractor will submit the following items for Painting and application of other coatings:

- JHA detailing the work plan

- Respiratory Protection Program

- Qualitative respirator fit test records

- Medical approval to wear respirators

- Respiratory protection training records

- Minimum of ½ mask, air-purifying respirator (Full face piece, air-purifying or Powered Air Purifying Respirators may be required depending on product, task, and environmental factors).

YES

YES

YES

YES

YES

YES

NO

NO

NO

NO

20. Sanitation NA Will the scope of work require the Contractor to provide temporary washing facilities and toilets?

YES NO

21. Silica Dust NA Will work involve jack-hammering, roto-hammering, drilling, grinding or other disturbance of concrete or use of products that contain crystalline silica that might create silica dust?

YES NO

Will work involve wet slab or wall concrete cutting, drilling, and coring or cutting/sanding drywall or joint compound?

YES NO

If “YES” to either of the above questions, describe below the method of dust control and control of worker and other persons who could be exposed, such as using wet methods and respiratory protection/training:

Subcontractor will submit the following items:

- JHA describing silica hazards and controls

- Subcontractor’s Respirator Protection Program

- For indoor work:

Quantitatively fit tested full face-piece, air-purifying respirator along with fit test records

- For outdoor work:

Qualitatively fit tested ½ mask negative pressure respirator along with fit test records

- Medical approval to wear respirators

- Respiratory protection training records

- Documentation of silica hazards awareness training

YES

YES

YES

YES

YES

YES

YES

NO

NO

NO

NO

NO

NO

NO

22. Company Related Programs NA Heat Related Illness Program Is heat related illness a potential hazard for this scope of work?

Is a heat related illness prevention program in place per Cal/OSHA requirements?

YES

YES

NO

NO

Ergonomics Program Does the Contractor have an Ergonomics Program in place? YES NO

23. Radiation and Laser Safety NA Will radioactive material/sources be used? YES NO

Will you be working on a class 3B or Class 4 laser? YES NO

Will you be working on a microwave source greater than 5mW/cm2? YES NO

Describe below:

Contractor shall perform and document a Job Hazard Analysis (JHA) to identify hazards and develop controls for site specific conditions.