Focus Worksite Verification Report

Date & Time: Company:

Locations:

Y/N
# 12. Personal Protective Equipment (N/A)
1 Head Protection
1.1 Is head protection worn where required?
1.2 Are hard hat suspension systems maintained in a safe manner?
1.3 Are hard hats free from damage (cracks, holes, or any damage)?
1.4 Do all electricians wear Type "E" hard hats?
1.5 Have Class "C" Hard Hats been prohibited and restricted from use?
2 Hand protection
2.1 Are gloves being worn by workers handling materials?
Are correct gloves being worn for the job? (Welding, tie cutting, electrical work,
2.2 chemicals, etc.)
3 Eye and Face Protection
3.1 Is proper eye protection worn in work areas at all times by all workers?
3.2 Do all safety glasses have side (rigid shield) protection?
3.3 Are face shields worn when required? Welders, Grinders, etc.
3.4 Have signs been posted at bench grinders indicating "Face shields required"?
3.5 Are safety glasses or mono goggles worn under face shields or welding shields?
Are chemical goggles and face shield worn for protection during handling chemicals
3.6 and fuels?
4 Breathing Apparatus
Respiratory protective protection (welding, grinding, dust, vapors, etc.) wore and
4.1 available.
Breathing apparatus for chemicals, confines Space rescue, etc, onsite, condition
4.2 good, etc.
5 Hearing Protection
5.1 Is hearing protection worn in areas with high noise levels?
Are workers wearing correct hearing protection for noise levels and duration of
5.2 exposure?

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Are their signage warning of high noise levels and requirement for wearing hearing
5.3 protection?
6 Fall Protection
Are full body harnesses required and used where fall exposure > 1.8 meters (6 feet)
6.1 exists?
6.2 Are harnesses numbered for inspection reference purposes?
6.3 Are all double lanyards equipped with shock absorbers?
6.4 Are lanyard hooks provided with locking safety latch to prevent "Roll Out"?
6.5 Are approved anchorage points used when required?
Is fall protection equipment used only for fall protection, and unapproved equipment
6.6 is not used?
6.7 Is fall protection equipment inspected on a regular basis and tagged accordingly?
6.8 Are only manufactured or engineered horizontal lifelines used?
7 Coverall/Protective Chemical Suits
7.1 Are all workers wearing full coveralls onsite (Flame Retardant)?
7.2 Are Chemical Suits (disposable- type ) being used?

Code
Person Sign as Date
List of Deficiencies (see
Responsible Complete Completed
below)

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 Focus Worksite Verification Report

A = Immediate action B = 24 Hours C = 48 Hours D = One Week

Inspection Team
PRINT SIGNATURE

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