The construction industry accounts numerous fatalities caused by the “Fatal Four” – falls, struck by object, electrocution, and caught between objects. These hazards were responsible for more than half of construction workers’ deaths. Use this template before commencing work on a construction project. Determine the hazards that may arise from the work activity to be performed. Use Lumiform to record significant data of detected risks like presence of electrical tools, an ongoing excavation activity, use of scaffolds and ladders, and handling of deadly substances and materials.
Description of the activity or work to be performed (Work scope)
Personal Protective Equipment
Select available and appropriate PPE to protect employees against hazards
Enter other PPE used
Hand and Power Tools
Will the work involve the use of electrically powered tools?
Will the work involve the use of pneumatically powered tools?
Will the work performed on this project involve the use of powder-actuated tools?
Ground & Surface Penetrations
Will the work scope require you to cut into, chip into, drill into, or make any other penetrations into walls, ceilings or floors?
Will the work scope require you to excavate, trench, dig, or otherwise penetrate into the ground (including use of stakes or poles)?
Will the work scope require you to penetrate into any concrete surface at any depth?
Have building surfaces or structures to be penetrated been evaluated for lead and asbestos?
Excavation and Trenching
Will this work scope involve any excavation up to 5 feet deep?
Will this work scope involve any excavation deeper than 5 feet?
Will this work scope involve sanitary sewer line repair or replacement?
Will this work scope involve storm sewer line repair or replacement?
Demolition
The subcontractor has signed off on the Isolation Plan: Electrical, Gas, Water, Steam, or other Utilities?
Subcontractor will submit the following items for Demolition Plan: - An Isolation Plan along with an SOP for startup.
Traffic & Pedestrian Control
Will this work scope require any traffic or pedestrian disruptions?
Blocking or partially blocking any roadway, walkway or driveway?
Hazardous Energy Control (LOTO)
Will you be doing any electrical work?
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?
Select non-electrical systems
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?
Will your work require you to overlock onto an existing LBNL LOTO lock to protect from hazardous energy?
Are you removing or opening any electrical equipment covers of electrical equipment? For example boxes, panels, disconnect switches, etc.
Are you doing any demolition work that will require the removal of electrical equipment, walls, partitions, building structures, piping systems, ducts, etc.?
Are you working on the travel path of a crane, hoists, or other equipment that present crush or pinch hazards?
Will your work require installing, repairing or modifying rotating equipment?
Will your work require the potential exposure to more than 250 volts?
Elevated Surfaces, Cranes & Heavy Equipment
Elevated Work Platforms
Enter other elevated work platforms used
Scaffolding
Other scaffold used
Ladders
Other type of ladder used
Cranes
Other type of crane used
Fire Protection & Prevention
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?
Will work be performed near combustible storage containers?
Will there be on-site refueling of equipment?
Has a Fire Watch been training in the use of fire extinguisher and emergency procedures for the work being performed?
Steel Erection and Assembly
Is steel erection part of this work scope?
Roofing
Will roof installation or roof repairs be performed?
Will you be on any roof performing work in your specific trade?
Will employees remain 15 feet back from the roof or other leading edges greater than 6 feet in height?
Will a warning line system (non-conforming guardrail) be used to delineate the 15-foot boundary?
Will work take place beyond the warning line?
Hazardous Substances and Materials
Will the work involve the use of any chemicals, such as paints, solvents, adhesives, epoxy coatings, fuels or other hazardous materials?
Will employees be potentially exposed to airborne concentrations of hazardous gas, fume, dust or mist?
Permit-Required Confined Space Entry
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?
Welding/Hot Cutting
Will the work involve welding/cutting steel at painted surfaces?
Will the work involve welding/cutting stainless steel?
Lead Paint
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?
Asbestos
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?
Application of Paint and other Coatings
Does the scope of your work include sanding, scraping, grinding, washing or other prep activity?
Silica Dust
Will work involve jack-hammering, rotohammering, drilling, grinding or other disturbance of concrete or use of products that contain crystalline silica that might create silica dust?
Will work involve wet slab or wall concrete cutting, drilling, and coring or cutting/sanding drywall or joint compound?
Radiation and Laser Safety
Will radioactive material/sources be used?
Will you be working on a class 3B or Class 4 laser?
Will you be working on a microwave source greater than 5mW/cm2?
Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.
