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Control House - Scale

T5 - Risk Assessment Manual being done daily and correct?

Yes No N/A

Check T5 Manual

Emergency Phone Numbers Posted?

Yes No N/A

Smoke Detectors working properly?

Yes No N/A
Hi there 👋

Do you need some help finding the

First Aid Kits Stocked? right form?

Yes No N/A
Yes, I'd like some help.

I want to import my own form.

Stairs and handrails in good working condtion?

No, I'm good. Thanks!

Yes No N/A
MSDS manual up to date?

Yes No N/A

Check one product and make sure its up to date in manual.

Radio communication with loader and ground employees?

Yes No N/A

Monthly Fire extinguishers inspection log done/or tags logged?

Yes No N/A

Housekeeping Good?

Yes No N/A

Plant horn works for start ups?

Yes No N/A
Hi there 👋

Do you need some help finding the

Pedestrian plan in place, map posted where it can be scene by customers?
right form?

Yes No N/A
Yes, I'd like some help.

I want to import my own form.

Windows clear, no obstructions to silos or loadout?

No, I'm good. Thanks!

Yes No N/A
 No fire hazardous, such as bad extension cords, trash can overfilled, flammable materials
not stored properly?

Yes No N/A

Personal Protective Equipment

Hard Hats, safety glasses, steel toe boots and hearing protection being worn?

Yes No N/A

Proper gloves being worn when handling materials?

Yes No N/A

If respirators are used (other than dust masks worn on a voluntary basis) employees are
medically qualified, trained and fit tested for respirator use?

Yes No N/A

Lockout / Tagout

Hi there 👋

Lockout / Tagout manual up to date and being used properly?

Do you need some help finding the

right form?
Yes No N/A

Yes, I'd like some help.

Valve covers and lockout equipment devices available? I want to import my own form.

Yes No N/A No, I'm good. Thanks!

 Each employee has his own lock?

Yes No N/A

Arch Flash equipment in good condition. Gloves, hardhat with face shield, Coveralls or
uniforms.

Yes No N/A

Are all electrical panels,breakers and disconnect boxes labeled properly with arch flash
lables?

Yes No N/A

Check lockout/tagout manual

Electrical Hazards

Is electrical wiring free of damage and fraying?

Yes No N/A
Hi there 👋

Do you need some help finding the

Are permanet splices in cables insulated to the equivalent of the oringinal, strong, and
right form?
sealed to moisture?
Yes, I'd like some help.
Yes No N/A
I want to import my own form.

No, I'm good. Thanks!

Are no repairs done to extension cords with the exeception of proper plug replacement?

Yes No N/A
 Are GFCI provided on outlets around water and all extension cords?

Yes No N/A

3 foot clearance around electrical boxes?

Yes No N/A

All electrical switches, breakers, etc. labled and warning signs posted around all
electrical installations?

Yes No N/A

Confined Space

Confine Space Manual in place and being used properly?

Yes No N/A

Confine Space Monitor being calibrated and logged? At least every two weeks?

Yes No N/A
Hi there 👋

Do you need some help finding the

Bump Test being performed before each entry and logged?
right form?

Yes No N/A
Yes, I'd like some help.

I want to import my own form.

All confined space areas properly labeled?

No, I'm good. Thanks!

Yes No N/A
 Check Confined Space Manual

Fall Protection/Fall Hazards

All fall protection in good working condition?

Yes No N/A

Date of first use logged on fall protection devices (PPE) tag?

Yes No N/A

Ladders being inspected before each use?

Yes No N/A

Check ladders for damage.

If employees are working at heights, is the area below barricade off half the distance they
are working? Hi there 👋

Yes No N/A Do you need some help finding the

right form?

Yes, I'd like some help.

All ramps bermed half the distance of the largest equipment being used on ramps?
I want to import my own form.
Yes No N/A
No, I'm good. Thanks!
 Barricades used under silo drop gate?

Yes No N/A

Stairs and Walkways

All stairs and walkways in good working condition?

Yes No N/A

Proper height on all handrails, at least 42"

Yes No N/A

Swing Gates on all working platforms?

Yes No N/A

Toe Boards on all Walkways?

Yes No N/A

Hi there 👋

Are housekeeping practices carried out to insure work area are safe from trip/fall
Do you need some help finding the
hazards to employees? right form?

Yes No N/A
Yes, I'd like some help.

I want to import my own form.

Guards
No, I'm good. Thanks!
 Are all belts and pulleys within 42 inches form the ground fully guarded?

Yes No N/A

Are all conveyor systems within 7 foot of walking/working surface equipped with a shut-
off cable or guard?

Yes No N/A

Liquid AC Loading and Unloading

All PPE in good working condition?

Yes No N/A

Hose and Coupling in good working condition?

Yes No N/A

Wheels chocks in good working condition?

Yes No N/A
Hi there 👋

Do you need some help finding the

Unloading Sign in place? right form?

Yes No N/A
Yes, I'd like some help.

I want to import my own form.

Haulers wearing proper PPE and following APAC procedures?

No, I'm good. Thanks!

Yes No N/A
 Take Photo of Loading Area 

Equipment

Daily equipment inspections being done daily?

Yes No N/A

Check one piece of equipment

Take picture of equipment and unit number 

Are good house keeping practices employed in cab of equipment?

Yes No N/A

Seat and seat belt in good working condition?

Yes No N/A
Hi there 👋

Do you need some help finding the

Mirror adjusted properly and good working condition? right form?

Yes No N/A
Yes, I'd like some help.

I want to import my own form.

Back up alarm working proplery?

No, I'm good. Thanks!

Yes No N/A
 Check decibles 15' foot behind equipment - Above 90 dbs?

Access steps and railing in good working condtion?

Yes No N/A

Are parking brakes capable of holding mobile equipment with typical load on max grade?

Yes No N/A

Conveyance and storage of materials under pressure

All compressed gas cyclinders secured in safe manner and properly capped when not in
use?

Yes No N/A

Are oxygen clyinders stored from flammable materials and at least 25 feet from
flammable gas cylinders?

Yes No N/A
Hi there 👋

Do you need some help finding the

Annual inspsection done on all pressure vessels/compressors?
right form?

Yes No N/A
Yes, I'd like some help.

I want to import my own form.

Are storage areas for cylinder bottles labled, Full and Empty?
No, I'm good. Thanks!

Yes No N/A
 Does all high pressure lines have the approved high pressure clamp? No raditor clamps?

Yes No N/A

Is compressed air used for cleaning purposes regulated to 30 pounds?

Yes No N/A

Add media 

Lifting Operations

All lifting implements such as straps, cables and chains have their load limit identified, as
applicable?

Yes No N/A

All safety latches in place?

Yes No N/A

Hi there 👋
Are employees lifting any material greater than 50 lbs?
Do you need some help finding the
Yes No N/A right form?

Yes, I'd like some help.

Fire Protection I want to import my own form.

No, I'm good. Thanks!

Are no smoking signs/labels posted around flammable materials?

Yes No N/A
 Flammable Liquids stored an approved Safety Can and Containers?

Yes No N/A

Are all spills cleaned up?

Yes No N/A

Unsafe Behavior

All CRH FFE's being observed/safe behaivor observed during this audit? If no, please
explain below, how it was corrected.

Yes No N/A

Other

Yes No N/A

Add signature 

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Yes, I'd like some help.

I want to import my own form.

No, I'm good. Thanks!