SAFE WORK PRACTICES Annual Review

SAFE WORK PRACTICES Annual Review

Safe Work Practices / Development / Review / Review
Date / By
Whom / Date / By
Whom / Date / By
Whom
M / D / Y / M / D / Y / M / D / Y

SAFE JOB PRACTICES Annual Review

Safe Job Practices / Development / Review / Review
Date / By
Whom / Date / By
Whom / Date / By
Whom
M / D / Y / M / D / Y / M / D / Y

Name of Company: Date/Time: Machine Make & Model: Unit #: Mileage: km/miles

ITEM / OK / REQUIRE ACTION / COMMENTS
Brakes
Steering
Tires
Air Tanks
Fluid Levels
Engine Belts
Suspension
£ Front
£ Rear
Hoist Rams
Main Frame
Rock Ejectors
Body Dump
Lights
Glass
Handrails
Ladders
Wheel Chock
Seat Belts
Fire Extinguishers
Back Up Alarm
First Aid Kit
Date: / Operator:
Supervisor: / Maintenance:

Equipment / Vehicle Checklist

Name of Company: Date/Time: Machine Make & Model:

Unit #: Mileage: km/miles

¨ Equipment Passed ¨ Equipment Not Passed

Work Required Assigned To Completion (Date/Time)

1.

2.

Repair Person’s Signature: Supervisor's Signature:

Tool Box Meeting

Company Name: / Date/Time:
Location & Project #: / Meeting Conducted By:
Type of work: / Number in Crew:
Foreman/ Supervisor: / Number Attending:
Review of Last Meeting & Comments:
Topic(s) Discussed this Meeting: / Have Each Attendee Clearly Sign Their Name
Employee Input:
Action(s) to be Taken (State date/ time to complete and by whom):
Incidents/ Accidents Reviewed:
Foreman/ Supervisor Signature:
Office Use
Reviewed By: Date:
(Manager’s Signature)
Comments:

Worksite Safety Inspection

Company Name: / Date/Time:
Location: / Project #:
Areas Inspected: / Inspection Conducted By:
Priority Index:
Severity 1. Imminent Danger 2. Serious 3. Minor 4. Negligible/Ok 5. Not Applicable
Probability A-Probable B-Reasonably probable C-Remote D-Extremely Remote
Hazard Number / Hazard Priority / Description of Hazard
What is the hazard and its location? / State a Corrective Action including when it will be completed and by whom / Who completed Corrective Action? Date/Time
Office Use
Reviewed By: Date:
(Manager’s Signature)
Comments:

Site Inspection / Hazard Assessment

Company Name
Location: / Date:
Areas Inspected: / Scope of Work:
PRIORITY RANKING:
SEVERITY PROBABILITY
1. Immediate Danger (death, disaster) A. Probable (immediate or soon)
2. Serious (major injury or damage) B. Reasonably Probable (eventually)
3. Minor (non-serious injury or damage) C. Remote (could at some point)
4. Negligible (first aid or less) D. Extremely Remote (unlikely)
Item
# / Identified Hazards
(Description & Location) / Priority / Control / Action:
(Dated Whom)
Critical Tasks:
Manager’s Signature: Date: / Approved By: Position:
Revised By: / Date:
Company Name:
General Location of Incident (e.g. Town/City/Street Address/Township Range):
Specific Location (e.g. inside/outside/building/vehicle):
Date of Incident (Y/M/D): /
Date Incident was reported: / / / Foreman/ Supervisor in Charge:
Time of Incident (include a.m., p.m.):
Time Incident was reported: / Incident reported by:
Incident reported to:
Name of Injured Worker:
Incident Type (circle all that apply): 1) Injury/Illness 2) Near Miss 3) Damage 4) Spill 5) Other
If Injury/Illness, was it a: 1) First Aid 2) Medical Aid 3) Lost Time 4) Modified Work 5) Fatality
Person(s) Involved including witnesses (witness statements are to be attached separately):
Name Address Phone Company
Conditions at time of the Incident (include elements such as weather, status of job, housekeeping,
visibility, etc.):
Description of Incident (tasks being performed, location of person(s), equipment being used, other work
activities, etc.):
Diagram:
What was the Direct Cause of the Incident?
What was the Indirect Cause(s) of the Incident?
Recommended action(s) to prevent re-occurrence in the SHORT TERM:
Date Recommendations to be completed by (Month/Day/Year):
Name of person(s) to complete recommendations:
Recommended action(s) to prevent re-occurrence for the LONG TERM:
Date Recommendations to be completed by (Month/Day/Year):
Name of person(s) to complete recommendations:
Estimated Cost of Incident:
Foreman/ Supervisor (Signature):
Date Reviewed: / Office
Managers Signature: Date Reviewed:
Person(s) conducting the Incident Investigation (signatures):
Date Reported Completed (Y/M/D): / / /
Company Name:
Date: / Project/Project #:
Location(s)/Department(s)/Area(s) involved in follow-up:
Following up on a (check appropriate report):
1) Tool Box meeting that was dated: ______
2) Inspection report that was dated: ______
3) Incident Investigation report dated: ______
4) Hazard Assessment that was dated: ______
Foreman/ Supervisor at that time was:
Corrective Action Assessment Team (Name/Position):
Priority Index Severity: 1. Imminent Danger 2. Serious 3. Minor 4. Negligible/Ok 5. Not Applicable
Probability: A-Probable B-Reasonably probable C-Remote D-Extremely Remote
Item# / Priority / Recommended Action / Was completed by whom? Date & Time
Ask this question: “Do the recommended corrective action(s) listed above reduce the potential of an incident?” If the answer is “NO”, “NOT WORKING” or “NOT ENOUGH” for any item, describe why it is not and make recommendations to implement below.
Item#
Reviewed by (Manager’s signature): ______Date: ______
Comments:
Training Program / Yes / Date Completed / Verified by
Certificate of Qualification
Apprenticeship Letter
WHMIS
Fall Protection
Propane
Forklift
Powered Platforms
Health and Safety Rep.
Certified Member
First Aid
CPR Training
Accident Investigation
Basics of Supervising
Fire Protection Training
Traffic Control
Powder Actuated Tools

All workers shall participate in weekly Toolbox Talks as part of their ongoing training.

Job Hazard Analysis (JHA)
Job:
Tools/Equipment Required / Material Required / Personal Protective Equipment
Steps / Sequence of Steps / Potential Accidents or Hazards / Recommended Safe Job Procedure
Developed By: 1. / 2. / 3.
Reviewed By: 1. (Name) (Position) / Approved By: (Name) (Position)
Revised By: / Date:
Page of

The information in this procedure does not take precedence over applicable government regulations, with which all employees should be familiar.

Company Name

Monthly Injury Summary Year:

Personal Injury Cases
Job Location / Lost Time Cases / Medical Referral / Days Lost / Frequency / Severity
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Total
Manager's Signature:
Date: / Average:

Company Name

Year-End Injury Summary Year:

Personal Injury Cases
Month / Lost Time Cases / Medical Referral / Days Lost / Frequency / Severity
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Total
Manager: Date: / Average:

Yearly Injury Summary

Company Name Year: ______

Personal Injury Cases
Year / Lost Time Cases / Medical Referral / Days Lost / Frequency / Severity
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Total
Manager: Date: / Average: