ASSA CONSTRUCTION

SITE INSPECTION CHECK LIST

Sl. No TABLE OF CONTENTS Page No

1 Scaffolding Inspection Check List 2-3
2 Height work Inspection Check List 4
3 Ladder Inspection check List 5
4 Electrical Inspection Check List 6-7
5 PPE Inspection Check List 8
6 Excavation Check List 9-10
7 Gas Cutting Check List 11
8 Welding inspection Check List 12
9 Building hoist and Winch inspection check List 13
10 Heavy material erection Check list 14
11 Mobile crane Inspection check List 15-16
12 Crawler crane Inspection Check List 17-18
13 Excavation Permit 19
14 Shaft permit 20
15 Night work Permit 21
16 Industrial radiography Permit 22-23
17 Blasting Permit 24-26
18 Electrical Permit 27-28
19 Weekly statistics Report 29
20 Monthly Statistics Report 30
21 Safety Inspection report 31
22 Contractor Near Miss Report 32
23 TBT Format 33
24 Induction Training Form 34
25 Labour Colony Inspection Check List 35-36
26 Incident Details Report 37
27 Diesel Generator Inspection Check List 38
28 Potable Tools Inspection Check List 39
29 Mobile scaffolding Inspection Check List 40
30 Vehicle Inspection Check List 41
31 Job Hazard Analysis Format 42
32 Fire Extinguisher Inspection Format 43
33 Infraction Notice Form 44
 ASSA CONSTRUCTION

SCAFFOLD SAFETY INSPECTION CHECK LIST

Project Name Report No.

Location Date
Name of the Contractor

NO. YES NO REMARK

ITEM OF INSPECTION
1. Is scaffold erected on ground?
2. Are proper soleplate used
Are proper base plate fitted to all standards or legs of
3.
scaffolds.
4. Are scaffold component connection fitted correctly.
Is standard connected and with either sleeve coupler or joint
5.
pin.
Is ledger bracing connected to the standards with right-angle
6.
coupler or ledger with swivel-coupler?
Is horizontal bracing lacing provided every 5 lift of frame to
both inner and out standards?
1. At every two (2) lift or at every floor starting from base
of maximum 4 meters.
2. Spaced not more than 3 bays or 7.5 meters apart
7.
whichever is lesser.
3. Spaced not further than one bay from ends in
staggered manner.
4. Effective temporary tie at top most working level, or
arm lock at least two lifts at upper most.
Is working platform provided as
Continuous working platform at construction level.
8. Isolated working platform provided with proper guardrail and
toe-board.
Size of working plat form is 635 mm, 860 mm or 1.1 meters.
9. Is proper access and egress to working platform provided?
Is the space between building face and working platform
10.
460mm or less?
11. Is 15 meter scaffold, design and checked by the P.E?
Is scaffolds erected one lift above the top most construction
12.
level?
Do scaffold components and fitting show any sign of
13.
deterioration?
Are scaffold and its working platform free from debris, unused
14.
formwork and scaffold component?
15. Tube and fitting
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1. Is ledger connected to t he standard with right angle

coupler?
Is transom connected to the standard with right angle
coupler?
2. Is bracing for tube and modular scaffold provided?
3. Is diagonal bracing connected either to projecting
transom with right angle coupler or to standard with
swivel coupler
16. Is foot-tie fitted to both inner and outer standards?
17. Is peripheral net properly installed?
18. Is there any designed person at the workplace?
19. Scaffold erection supervised by competent person.
20. Is there a scaffold register for inspection record?

Checked By Reviewed By

Contractor Representative ASSA CONSTRCUTION Representative

CHECKLIST FOR WORK AT HEIGHT

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Project Name Report No.

Location Date
Name of the Contractor

Sl. Description of Check Point Yes No. NA Remarks

No.
1 Are all the heights protected with proper barricades and
scaffoldings?
2 Has proper walkway or foot board provided on top?

3 Are workers using fall protection belts / full body harness

where it is not possible to provide railing?
4 Is ladder being provided for proper access?

5 Is ladder being secured from top and bottom and protrude

at least 1 mtr. From the point of landing?
6 Is everyone instructed for using the ladders one at a
time?
7 Is the ladder provided and placed at safe angle (in the
ratio of 1:4)?
8 Are the platform, ladders and landings strong enough

9 Is the platform / landing made with factor of safety, of

sound materials and good design, clean and well kept
tied up?

Note: Refer to SOPs / Check list related to ladders, Scaffolds, Stairs, Stair Towers, and Ramps
etc for details.

Checked By Reviewed By

Contractor Representative ASSA CONSTRCUTION Representative

CHECK LIST FOR LADDER INSPECTION

Project Name Report No.

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Location Date
Name of the Contractor

SL.NO. DESCRIPTION OF CHECK POINT YES NO NA REMARKS

1 Are ladders the right means of access for the job?

2 Are all ladders in good condition?

Are the secured to prevent them slipping sideways or
3 outwards?
Do ladders rise to a sufficient height? Above their landing
4 place? If not there hand hold available?
Are the ladder positioned so that used don't have over
5 step or climb over obstacles to work?

Does the ladder rest against a solid surface and not on

fragile or insecure materials?
6
Whether the position at an angel 1:4?
7

Whether it is adequately secured?

8
Is the space between the rungs are even and uniform?
9
Whether any bamboo ladders are used by
10 subcontractors?

Whether the metal ladders are painted by any

11 subcontractor?

Checked By Reviewed By

Contractor Representative ASSA CONSTRCUTION Representative

ELECTRICAL SAFETY INSPECTION CHECK LIST

Project Name Report No.

Location Date
Name of the Contractor
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Sl. Description Yes No Action Required

No.
A. Electrical Engineer / Supervisor available
at site
B. Licensed Electrician at site
C. Power Panel
1. Check operation of each feeder
2. Fuses of proper rating present
3. Tightening of Bass Bar made
4. Tightening of earth connection checked
5. Cleaning of panel
6. Spare holes / opening closed
7. DCP / CO2 fire extinguisher installed /
checked
D. Distribution panel
1. Fuse rating of incoming & out going feeder
checked / recorded ok
2. Operation of each feeder switch checked /
recorded ok
3. Tightening of earth connection to DB and all
switches checked.
4. Tightening of power cable of incoming and
outgoing feeders checked
5. Operation of ELCB checked and recorded
6. Spare holes / opening closed
7. Proper outgoing of DBs.
E. Cables
1. All flexible cables and cables joints are above
ground levels.
2. Cable markers are in proper position.
3. Tightening of cable connection at panel and
equipment checked.
4. Safety tags placed for underground cables.
5. Cables used are corrected ratted
F. Earthing
1. Earthing connection with all electrical
equipments checked
2. Tightening of earthing checked.
3. Earthing resistance value checked and
recorded.
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G. Lighting
1. Power connection to fixtures with 3 core
flexible wire made.
2. Condition of protective glass covers for
halogens in place / in good condition.
3. Rigid frame work of lighting fixture pole at site.
4. Protective insulation of cables is ok.
H. Miscellaneous
1. Rain protection for power panel / DBs / plug
sockets, welding machine and DG set
arranged.
2. Ease access to all electrical power panels,
DBs, welding machines and DG sets at site.
3. Switch operation for welding machine in right
order.
4. Welding cables and electrical cables are
separately laid.
5. Danger board / caution notice displayed.
6. Use of good and insulated tools checked and
recorded.

Checked By Reviewed By

Contractor Representative ASSA CONSTRCUTION Representative

CHECKLIST FOR PERSONAL PROTECTIVE EQUIPMENT

Project Name Report No.

Location Date
Name of the Contractor

Sl. Description of Check Point Yes No. NA Remarks

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No.
1 Appropriate eye protection is available and used if
hazards present.
2 Appropriate hand protection is available and used if
hazards present.
3 Appropriate hearing protection is available and used
if hazards present.
4 Appropriate foot protection is available and used if
hazards present.
5 Protective clothing (coverall, apron, etc) available
and used if needed.
6 Approved respirators available and used if needed.
7 PPE is properly stored, clean and in good condition.
8 Use of safety belt while working at height.
9 Safety goggles during welding / Gas cutting /
grinding etc.
10 Proper types of gloves are used for appropriate type
of works.
11 Use of safety helmet & safety shoe ensured for all
workers.
12 Anchoring point providing at all places of height
work.
13 Safety nets are in use wherever required.
14 Common life line provided wherever linear
movement at height is required.
15 Proper fall arrest system is deployed ay critical work
places.
16 Has a list of required PPE for each area / operation
been developed and the required PPE is made
available to the workers?
17 Are the EHS department and the workers consulted
in the selection of PPE?

Checked By Reviewed By
Contractor Representative ASSA CONSTRCUTION Representative
CHECKLIST FOR EXCAVATION

Project Name Report No.

Location Date
Name of the Contractor

Sl. Description of Check Point Yes No NA Remarks

No.
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1 Is an adequate supply of timber, trench sheets props of the

supporting material made available before excavation work
begins?
2 Is this material strong enough to support the sides?

3 Is a safe method used for putting the support i.e. one that
does not rely on people working within an unsupported
trench?
4 If the sides of the excavation are sloped back or battered. Is
the angle of batter sufficient to prevent collapse?
5 Id there safe access to the excavation?
6 Are there guard rails or other equivalent protection to stop
people falling in?
7 Are properly secured stop blocks provide to prevent tripping
vehicles falling in?
8 Does the excavation affect the stability of neighboring
structures?
9 Are materials, soil or plant stored away from the edge of the
excavating or order reducing the likelihood of a collapse of
the side?
10 Is the excavation inspected by a competent person at start
of every shift?
11 Has the risk of manual handling injuries been assessed

12 Are hoists, wheel barrow and other plant or equipment used

so that manual lifting and handling of heavy objects is kept
to a minimum?
13 Can the handling of heavy blocks be avoided?

14 Whether the verification for the underground electrical cable

line?
15 Avoid traffic movement, piling work in the vicinity

16 Are the dewatering facilities are adequate?

17 Are the barricade / fencing / displaying of dangers sign,

warning sign byway of red flag/tape/light etc.
18 Whether the provisions for ladders for deep trench?

Checked By Reviewed By

Contractor Representative ASSA CONSTRCUTION Representative

 ASSA CONSTRUCTION

CHECKLIST FOR GAS CUTTING EQUIPMENT

Project Name Report No.

Location Date
Name of the Contractor

Sl. Description of Check Point Yes No Remarks

No.
1 Are acetylene cylinders kept in upright position and secured at
designated place under shelter?
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2 Whether oxygen & acetylene cylinders are stored separately?

3 Whether color coding is being used for easy identification of
different type of cylinders and hoses?
4 Check cylinder & cylinder valves for any kind of damage?
5 Whether protective valve cap are kept on the cylinder while
not in use?
6 Whether proper means and method for transportation of
cylinder to avoid dropping & rolling area being adopted?
7 Whether regulators are kept away / free from oil & grease?
8 Whether all hoses were found to be free of any damage or
crack?
9 Whether cylinder key are available near the cylinder?
10 Whether both the gas cylinder end and torch end of the hose
are provided with Non-return valve and Flash Back Arrestor?
11 Whether pressure gauges are working condition and checked
and calibrated from time to time?
12 Whether hose are connected with both the cylinder and torch
with proper hose clamps?

Checked By Reviewed By

Contractor Representative ASSA CONSTRCUTION Representative

CHECKLIST FOR WELDING EQUIPMENT

Project Name Report No.

Location Date
Name of the Contractor

Sl. Description of Check Point Yes No Remarks

No.
1 Whether proper earthing for welding machine is provided?
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2 Whether welding cables are maintained in good condition and

without any cable joints / cuts?
3 Whether the cables are laid properly without causing
obstruction in path?
4 Whether the connection between cable and electrode holder
properly tighten?
5 Whether earth connector is securely connected to the job and
not to the adjoining structure or scaffold?
6 Whether proper lugs used to connect cables with the welding
machine?
7 Whether fire extinguisher is available near welding area?

Checked By Reviewed By

Contractor Representative ASSA CONSTRCUTION Representative

CHECKLIST FOR BUILDING HOIST/ WINCH

Project Name Report No.

Location Date
Name of the Contractor

S. Description OK/ Remarks

No Not OK
A. SUPPORTING STRUCTURE:
1 Condition of steel tubes
2 Condition of the Base
3 Bracing (diagonal/horizontal)
4 Anchorage with structure
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5 Any obstructions to the movement of rope?

B. WINCH MACHINE:
1 Condition of brakes and accessories
2 Functioning of brake with load
3 Oil level and condition
4 Gear box and motor
5 Coupling bolts and nuts
6 Condition of wire rope
7 Anchorage of drum and wire rope
8 Pawl arrangement for locking
9 Condition of diversion pulleys, idlers pulleys and fleet angle
10 Limit Switches
11 Electrical connection, earthing and insulation
C. UNLOADING PLATFORM:
1 Area Barricaded
2 Stability
3 Sagging
4 Any Over loading
5 Hand railing
6 Staging
D. OTHERS
1 Is the person authorized/experienced to Operate?
2 Does the person at unloading point use Safety belt?
3 Is the bucket overloaded?
4 Is the Signaling Man present?
5 Is the work permit Obtained?

Checked By Reviewed By

Contractor Representative ASSA CONSTRCUTION Representative

Checklist for Heavy Equipment / Material Erection

I.
1. Name of the Contractor:
2. Date of Erection
3. Location of Erection
4. Material / Equipment to be Lifted
5. Dimensions of the Material / Equipment
6. Lift Quadrant zone
II.
1. Type of Crane
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2. Boom Length
3. Jib Length (If Any)
4. Radius of operation
5. Capacity at above Radius
6. Crane Load Tested Yes No
7. If any
Operating radius
Boom Angle
Boom point Elevation
Capacity
Test Load
III.
1. Effective Weight of Jib
2. Effective weight of Jib overhaul ball
3. Slings
Numbers Size Length Capacity Weight

4. Shackles
Numbers Size Length Capacity Weight

5. Weight of spreader bar

6. Weight of other rigging tools & tackles
7. Weight of equipment / material
8. Total erection load

Remarks:

Checked By Reviewed By
Contractor Representative ASSA CONSTRCUTION Representative

CRANE INSPECTION CHECK LIST

Inspection Date Location Date

Registration No. Make Serial No.

Name of Crane Operator Type of Crane

FINDING/RESULTS
ITEM DESCRIPTION
OK YES NO N/A REMARKS
1.0 APPEARANCE
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1.1 Paint
1.2 Cab
1.3 Windscreen
1.4 Wiper
1.5 Engine Instruments Functioning
2.0 BOOM
2.1 Extent Boom (Telescoping booms)
2.2 Boom Up
2.3 Swing
2.4 Hook Condition
2.5 Safety Latch
3.0 INDICATORS
3.1 Angle Indicator
3.2 Load Indicator
3.3 Radius Chart
4.0 BRAKES
4.1 Brake Lights
4.2 Brake Fluid
4.3 Parking Brake
4.4 Hoists brakes
5.0 TRANSMISSION
5.1 Shifting
5.2 Slipping
5.3 Noisy
5.4 Oil Level Condition
6.0 TYPE CONDITION
6.1 R.F
6.2 L.F
6.3 Front Axle Right (Inner, Outer) Tyre
6.4 Front Axle Left (Inner, Outer) Tyre
6.5 Rear Axle Right (Inner, Outer) Tyre
6.6 Rear Axle Left (Inner, Outer) Tyre
7.0 OUTRIGGERS (MOBILE CRANE)
7.1 R.F
7.2 L.F
7.3 R.R
7.4 L.R
FINDING/RESULTS
ITEM DESCRIPTION
OK YES NO N/A REMARKS
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8.0 ROPES
8.1 Greased
8.2 Checked For Wear
Ropes Lying On Sheaves And
8.3
correctly On Drums
9.0 BATTERY
9.1 Level and Condition
10.0 LIGHTS
10.1 Head lights
10.2 Signal lights
12.0 CONTROLS
12.1 Tested and Functioning
13.0 SAFETY DEVICES
13.1 Load Cell working
13.2 Limit Switches
13.3 Emergency Stop Tested
14.0 HYDRAULIC
14.1 Serviced
14.2 Any Leaks
15.0 TRACK SHOE (CRAWLER CRANE)
15.1 Slack Wear On Track Shoes
15.2 Excessive Wear On Track Shoes
15.3 Condition Of Retaining Bolts
15.4 Condition Of Track Cogs
15.5 Track shoes Have been Greased

Checked By Reviewed By
Contractor Representative ASSA CONSTRCUTION
Representative

CHECKLIST FOR CRANE INSPECTION

DATE : MACHINE NO :

LOCATION : IDENTIFICATION :
TESTED DATE : OPERTOR NAME :
DUE DATE : CHASSIS NO :
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ITEM DESCRIPTION GOOD SATISFACTORY UNSATISFACTORY

1 Driver Cabin

2 Wind Screen

3 Wiper

4 Boom

5 Swing Condition

6 Hook Condition

7 Safety Latch

8 Angel Indicator

9 Load Indicator

10 Load / Radius Chart

11 Brake Lights

12 Parking Brake

13 Hoists Brake

14 Tyre Condition

Front
Rear
15 Wire Ropes Condition
Ropes lying on sheaves
16
& correctly on drums.
17 Head Light

18 Signal Light

19 Limit Swatches
Emergency Stop Limit
20 Switch Function
Engine Condition Oil
21 Spillage
22 Hydraulic Oils any Leaks

23 Condition of Track Cogs

Condition Of Track
24 Shoes
 ASSA CONSTRUCTION

Checked By Reviewed By

Contractor Representative ASSA CONSTRCUTION

Representative

EXCAVATION PERMIT

Permit No: __________________ Date: ________

Project Name: _______________ Location: _________
Contractor: _________________ Sub-contractor: _____________

Excavation details:

Purpose: _______________________________________________________________
Area/ Location: __________________________________________________________
Proposed date and time for start of work: ______________________________________
Proposed date and time for completion of work: ________________________________
Tools and equipment involved: ______________________________________________
_______________________________________________________________________
_______________________________________________________________________
 ASSA CONSTRUCTION

Length __________ m Width __________ m Depth ___________ m

Preparation
1. Underground cables, pipelines, electrical lines etc checked Yes/No
2. Personnel protective equipments to be used to include;
A. Safety Shoe Yes/No
B. Safety Helmet Yes/No
C. Gloves Yes/No
D. Eye Protection Yes/No
E. Ear Protection Yes/No
F. Nose Mask Yes/No

Safety Precautions
1. The proper approach arrangement to be made with required no. of exit points
2. Wear proper PPEs
3. Barricade area and Display Warning boards
4. Ensure good housekeeping before and after the work
5. Ensure the presence of supervisor during the execution of work
6. Use certified machinery
7. Check for possible interference with any underground utilities
8. Check reverse horn for vehicles and driver license
9. Any special safety precautions (specify) ______________________________

Checked By:
Contractor’s Safety Officer Signature Date

PERMIT ISSUING AUTHORITY (Permit is granted & valid up to)

1. Date: _________ Time: ______ Signature of Safety Officer ______

Permit is revalidated for the Period

2. Date: _________ Time: ______ Signature of Safety Officer ______

SHAFT WORK PERMIT

Date: ___________ Permit no.: ________

Project name and Location: ________________________________________________

Name of the agency requesting permit: _______________________________________
Location of work: Shaft number: _______________ Floor: ________________________
Task to be performed: ____________________________________________________
Start date and time: __________________ Finish date and time: __________________

Safety Precautions required:

No. Item Yes Not required

1 All personnel are wearing proper PPE
 ASSA CONSTRUCTION

2 Workers have been briefed about hazards

3 Safe access to shaft available
4 Safe working platform erected
5 Safety harness with lifeline provided
6 Fire extinguisher provided for hot work
7 Shaft appropriately barricaded

Names of workmen entering shaft: _____________________

_____________________
_____________________

I have ensured that the safety precautions as listed above for the task to be performed have been taken
for this shaft work.

___________________ ____________________ ___________________

Name of Permitee Signature of Permitee Designation

___________________ ____________________ ___________________

Name of Issuing authority Signature of Issuing authority Designation

Notes:
1. Separate permit required for work in each shaft.
2. Work permit is valid for the prescribed date, time and in prescribed location only.

Time ________ Date ___________ Permit is closed.

Name and Signature of the Issuing authority: ______________________________

NIGHT WORK PERMIT

Permit No.: ______________________________ Date: ________________________

Project name: ____________________________ Location: _____________________

Contractor name: _________________________ Trade Package: ________________

Activities scheduled for night work with location:

Reason for conducting these activities at night:

 ASSA CONSTRUCTION

Name & contact No. of the Supervisor:___________________________________________

Name of workers and designation:______________________________________________
S.No NAME DESIGNATION

Sufficient lighting provided: YES/NO

Area to be cleaned after work:
Emergency vehicle available:
Any other special precautions:
Signature:______________
Project Engineer (Contractor)
YES/NO
YES/NO Vehicle No.:
Signature: _______________Signature: ______________
Project In-charge (Contractor) Safety Officer (Contractor)

Signature: _______________________________ Signature: ____________________

Project Engineer/Construction Manager (ASSA CONSTRCUTION) Safety
Representative (ASSA CONSTRCUTION)
Note: CONCERNED AGENCIES ARE RESPONSIBLE FOR ANY UNSAFE ACT / CONDITIONS

INDUSTRIAL RADIOGRAPHY – WORK PERMIT

Permit No.: Date:

Name of the Project: Location:
Name of the Contractor:

A) Person taking permit /permittee to fill up:

1) Exact location where Radiography work is being planned____________________________________
2) Approximate duration of work From: Date:____________ Start Time_____________ Finish Time_____
3) Description of work:__________________________________________________________________
4)Type of Radiography Radioisotope Neutron X-Ray Device
 ASSA CONSTRUCTION

For X-Ray Device

Manufacturer_______________________________________________ Device Type _____________
Model No.________________________________________ Serial _____________________________
kVp_____________ mA________________________________________________________________
Average duration of irradiation per shot: ______________ Approximate number of shots
required:_______________

Points to be checked
Sl.No Details Status
Yes No Not Required
1 Are all access to radiography site been blocked by caution
tape?
2 Are all personnel been vacated from the site before starting
the radiography?
3 All combustible removed from the radiography area
4 Relevant areas of potential exposure will be posted with
warning signs
5 Have fire extinguishers been kept handy at site?
6 Whether Proper PPE’s are available?
 Full Face shield
 Full Leather Gloves
 Full Body Cover all
7 Is Job Hazards Analysis (JHA) approved (mention the JHA
Sl.No)
The above points have been complied with and conditions rendered safe / hazards innocuous to undertake the
radiography work.

Name of the Certified Radiographer: _________________________________

Signature of Certified Radiographer:___________________________________

A.Permittee
I have ensured that the safety precautions as listed above for the task to be performed have been taken for this column concrete works.

Signature: ______________ Signature: _______________ Signature: ______________

Contractor’s Site Engineer Contractor’s Construction Manager Contractor’s Safety Officer

B.The person giving permit (Issuing Authority) to fill up:

The precautions and safe conditions mentioned above have been verified and the work can be started.

Signature: ______________ ___________________

Services Engineer / Manager (ASSA CONSTRCUTION) Safety Representative
(ASSA CONSTRCUTION)

C. Closing
Time ________ Date ___________ Permit is closed.

Name and Signature of the Issuing authority: ______________________________

 ASSA CONSTRUCTION

PERMIT FOR BLASTING WORKS

Permit No.: Date:

Project Name: Location:
Contractor: Sub-contractor:
Job description: Area/ location:

Remarks
A. Before Blasting YES NO N/A
1 Instruction to Personnel regarding hazards and working procedure
2 Notification To Other Contractors
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3 Whether the blaster is authorized license holder

4 Whether the explosive have been stored in approved magazines.
5 Whether detonators are checked individually for continuity &
resistance
6 Whether all detonators belong to same manufacturer.
7 Whether the explosive and detonators are of approved quality
8 Whether the condition of lead/ leg wires are checked
9 Personnel are taken to respective ' SHELTER ZONE' and the area
been cordoned off and all persons maintained to a safe distance
10 Whether stemming of holes is done by wooden tamping sticks.
11 Head counts are matched after crosschecking with respective
access controller
12 Are all electronic items/ radios, mobile phones, pagers electric
power circuits and lights in the vicinity within 70m of loading points
are switched off
13 Whether danger zone is suitably cordoned and flagmen posted at
important points.
14 Whether Suitable warning boards are displayed at site.
15 Whether Blaster shelter is available in good condition
16 Is the emergency van kept ready.
17 Has the alert siren given 3 times before blasting.
18 Has the local authority has been informed about the blasting time.
19 Any other Precautions taken:-
……………………………………………………………………………
…………………………………..

Tick As Applicable
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Barricades, warning signs Banksman / Flag man Explosive & detonator Check

Escape route + kept Clear Siren / Hooter Road block

Ear Plug Fitness of Lead / leg wires Competent Blaster

Respirators / Gas mask Eye protection Wooden Handled tools

Ventilation Miscellaneous Method Statement

Risk Assessment Prohibition Electronics Devices

Additional Safety Precaution / Remarks :-

I have checked the above points and found conditions suitable to undertake the work:

Reviewed & Checked by Name, Date & Signature of permit Applicant Eng./ Sup

Verified & Satisfactory Name, Date & Signature of Area In charge of G&B/ ASSA
CONSTRCUTION

B. After Blasting Remarks

1 Weather any miss fire detected YES NO N/A
2 Ensure respective shelter zone fan put 'ON' first
3 Remaining Explosive & Detonators are cleared from the area.
4 Weather all clear siren / signal blown or conveyed.
5 Gas testing carried out & ensure the gas limits
6 Whether after 5 minutes of blast, a careful inspection of the face is
made by the expert to.
7 Whether explosive reconciliation records are maintained..
8 Send information to access controller after defuming is completed.
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I, declare that mentioned attributes has been checked & complied with and conditions rendered
safe to allow to work

Reviewed & Checked by Name, Date & Signature of permit Applicant Eng./ Sup

Verified & Satisfactory Name, Date & Signature of Area In charge of G&B/ ASSA
CONSTRCUTION

To be filled by contractor safety engineer

Time: ______________ Date: ____________________at which blasting permit closed

We the undersigned, hereby confirm to perform the above mentioned work in compliance with the
relevant legal requirements, industrial practices, site rules and regulation, and G&B guidelines.
Implementation of above safety standards /precautions shall be the sole responsibility of the
contractor performing the work. The site management of the G&B/ PMC assumes no liability in this
regard.
 ASSA CONSTRUCTION

PERMIT FOR ELECTRICAL WORKS

Permit No.: Date:

Project Name: Location:
Contractor: Sub-contractor:
Job description: Area/ location:

Measures Remarks
YES NO N/A
1 Instruction to Personnel regarding hazards and working
procedure
2 Notification To Other Contractors
3 Does the job require HT license holder? If yes, is he
available?
4 Is the equipment isolated from all source of supply.
5 Are lockout device fixed at all point of isolation.
7 Is caution Sign fixed at all points of isolation.
8 Has the equipment been proved dead by competent
electrician?
9 Are safety lock fixed to secure temporary earth.
10 Where the work involves a cable has it been identified with
certainty?
11 Has lockout key handed over to the responsible person?
12 Whether working area has been barricaded/ isolated.
13 Whether tag out or warning tag is secured onto the energy
isolating point
14 Are the mandatory PPE's like rubber gloves, shoes, helmet,
emergency light etc… with electrical resistance provided?
15 Any other Precautions taken:-
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Barricades, warning signs Light / Illumination Access Escape route + kept

Clear Safety harness with lifeline tags First- Aid High -Visibility Cloth

Equipments Fitness Work Permit for other activity Worker Fitness Eye protection

Wooden Handled tools LOTO Others

Additional Safety Precaution / Remarks :-

I declare that apparatus / equipments mentioned above is safe to work and shutdown is
given and the same will not be made alive till the permit is cancelled in writing by the
person taking shutdown.

Person Issuing Shutdown (Electrical / P&M In charge - Contractor ):

Name / date/ signature

Permit Applicant (Person Taking Shutdown) - Contractor

Name / date/ signature

Note: - We the undersigned hereby confirm to perform the above mentioned work in
compliance with the relevant legal requirements, industrial practices, site rules and
regulation, and G&B guidelines. Implementation of above safety standards /precautions
shall be the sole responsibility of the contractor performing the work. The site management
of the G&B? PMC assumes no liability in this regard.

WEEKLY EHS STATISTICS REPORT

 ASSA CONSTRUCTION

Project: Date:

Report No:

Name of Contractor: M/s. Trade:

Sl# Description Status

1 No. of Man-hours worked over last week
2 Cumulative Man-hours worked till date
3 No. of Reportable Accidents on project
4 No. of Near Misses
5 No. of Lost Work Day (LWD) cases
6 No. of Safety Pep talks conducted
7 Infraction Notices/ Safety Inspection Reports received
8 Infraction Notices/ Safety Inspection Reports closed
9 No. of Fire extinguishers available at site (all types)
a Foam Type (Last serviced on )
b CO2 Type (Last refilled on )
c Others
10 No. of Training sessions conducted
a Fire fighting training
b First Aid training
c PPE Usage training
d Others
11 Safety Permits Issued
12 No. of Safety sign boards displayed at site
13 Housekeeping practices (Excellent/ V Good/ Good/ Average/ Poor)
14 No. of times Equipment, Machinery and Tools inspected
15 Physical condition of the PPE in usage (Good/ Average/ Poor)
16 License and vehicle documents available (if applicable)
17 Percentage compliance on the usage of PPE by workers

Submitted by:
Contractor Safety Representative/ Site In-Charge

ASSA CONSTRCUTION Safety Representative Comments (if any):

 ASSA CONSTRUCTION

MONTHLY EHS STATISTICS REPORT

Project: Date:

Report No: Trade:

Name of Contractor: M/s.

Sl# Description Status

1 No. of Man-hours worked over last month
2 Cumulative Man-hours worked till date
3 No. of Reportable Accidents on project
4 No. of Near Misses
5 No. of Lost Work Day (LWD) cases
6 No. of Safety Pep talks conducted
7 Infraction Notices/ Safety Inspection Reports received
8 Infraction Notices/ Safety Inspection Reports closed
9 No. of Fire extinguishers available at site (all types)
a Foam Type (Last serviced on )
b CO2 Type (Last refilled on )
c Others
10 No. of Training sessions conducted
a Fire fighting training
b First Aid training
c PPE Usage training
d Others
11 Safety Permits Issued
12 No. of Safety sign boards displayed at site
13 Housekeeping practices (Excellent/ V Good/ Good/ Average/ Poor)
14 No. of times Equipment, Machinery and Tools inspected
15 Physical condition of the PPE in usage (Good/ Average/ Poor)
16 License and vehicle documents available (if applicable)
17 Percentage compliance on the usage of PPE by workers

Submitted by:
Contractor Safety Representative/ Site In-Charge

ASSA CONSTRCUTION Safety Representative Comments (if any):

__________________________________________________________________________________
__________________________________________________________

Reviewed by:
ASSA CONSTRCUTION Safety Representative

Copy to: ASSA CONSTRCUTION Project Manager

 ASSA CONSTRUCTION

SAFETY INSPECTION REPORT

Project: ____________________________Report No.: ________ Date: ___________

Name of Contractor: ____________________________________________________

Number of non-conformities observed (as per details below): ____________________

Details of Non-Conformities observed:

The following non-conformances with reference to project EHS guidelines were observed during routine
EHS round of the project site;

Sl. # Description of non-conformity Target date

1
2
3
4

Note:
Please take serious note of the above listed non-conformities and initiate corrective action immediately,
so as to remove the non-conformity by the Target dates indicated above, failing which ASSA
CONSTRCUTION shall proceed with imposition of penalty for the observed non-conformities.

ASSA CONSTRCUTION Safety Representative

Contractor’s Corrective Action Response (To be filled by contractor):

All the above listed non-conformities have been rectified. The work is now being executed in
compliance with EHS guidelines and applicable Safety Standards. The disposition of the non-
conformances is listed as under;

Sl# Disposition Description Status

1
2
3
4

Contractor’s Site In-Charge Contractor’s Safety Representative

Dated: ___________

Copy to: ASSA CONSTRCUTION Project Manager

 ASSA CONSTRUCTION

CONTRACTOR INCIDENT/ NEAR MISS REPORTING FORMAT

Project: _________________________________ Location: ____________________________

Name of Contractor: ___________________________________________________________
Name of Contractor Employee: ______________ Age: _________ Sex: __________________
Incident Date: __________ Incident Time: _________ Incident Location: __________________
Injuries: _____________________________________________________________________
Treated by: ________________________ Treated at: _________________________________
Type of Incident (First aid/ Recordable/ Lost Work day/ Fatal/ Near Miss): _________________
Task assigned to person at the time of incident: ______________________________________
____________________________________________________________________________

Description of the Incident: _____________________________________________________

____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

Primary Root cause for the Incident: _______________________________________________

____________________________________________________________________________
____________________________________________________________________________

Contributory factors: ___________________________________________________________

____________________________________________________________________________
____________________________________________________________________________

Date when latest safety training was given to employee: _________________________________

Subject of training: ____________________ Given by: ________________________________
Was a Pre task plan required/ submitted for this task: _________________________________
Is there a standard procedure developed to perform this task? __________________________
If yes, was it reviewed with the worker and when? ____________________________________

Preventive measures proposed to avoid recurrence in future: ___________________________

____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

Contractor Site In-Charge Contractor Safety In-Charge

 ASSA CONSTRUCTION

SAFETY TOOL BOX TALK REPORT

Project: Location:

Date & Time of Tool Box talk given:

Topic of the tool box talk:

Tool box talk given by:

No. of workmen participated:

Sl.No. Name Designation Id Card No. Signature

Signature of Safety Representative

 ASSA CONSTRUCTION

INDUCTION FORM
Project:
Site Safety Management Matters - Identify points covered by induction by  in box
1. SUPERVISION site management structure. 11. CLIENTS RULES detail any client specific rules
2. EMERGENCY alarm procedure/muster point. 12. ACCIDENT and INCIDENT reporting procedures
Including near miss incidents
3. SMOKINGS identify any smoking restrictions. 13. DISCIPLINARY ACTION for safety related failings
4. FIRST AID arrangements on site. 14. PPE requirements for boots, eye & hearing protection,
respirators & overalls etc.
5. ENTRY ROUTES TO SITE give details for both 15. SAFETY HELMET as directed by site management in
Pedestrian & Vehicle routes accordance with site rules
6. ACCESS RESTRICTIONS detail any areas which 16. NOISE nuisance noise & restrictions on working hours
are out of bounds (Section 60 notices) & noise assessment procedure
7. ALCOHOL consumption of alcohol, taking of non- 17. NO RADIOS operating from leads. NO WALKMANS
prescribed drugs is not permitted. or other in ear audio device
8. HAZARD REPORTING detail procedures. 18. SECURITY arrangements & right of search etc.
9. WELFARE no eating on site. Site canteen/toilet 19. STATUTORY CERTIFICATES required for , lifting
Arrangements. Identify smoking restrictions appliances, electrical power tools etc.
Arrangements
10. SITE RULES give details
WORKING ARRANGEMENTS - Identify points covered by induction by  in box
20. SAFE WORKING risk assessments & method 28. COSHH before using chemicals, cutting, grinding, or
statement explained mixing materials obtain assessment. If in doubt ASK!
21. SITE VEHICLES, PLANT & MACHINES only to 29. SCAFFOLD not to be erected, dismantled or altered
be operated by authorized person, with proof of except by authorised persons. Proof of training &
training & competence certificate (CITB etc) competency is required. (Includes towers.)
22. TRAFFIC MANANGEMENT Vehicle/pedestrian 30. MATERIAL STORAGE & WASTE DISPOSAL
routes. Speed limits arrangements & procedures
23. FIRE PREVENTION location and type of fire 31. MANUAL HANDLING maximum weights &
fighting equipment. assessments.
24. PERMIT TO WORK describes procedure. 32. MATERIAL HANDLING to be lowered not thrown
25. TOOLS. Personal hand tools should be inspected 33. SAFETY MONITORING ARRANGEMENTS safety
regularly and any defects corrected. inspections & site instructions etc.
26. ENVIRONMENT conditions and special 34. CONSULTATION ARRANGEMENTS. You are
arrangements relating to this site. encouraged to discuss any constructive aspects of safety.
Personal Details 

Name:
Contractor Name:

Work Experience:
Nature of work allotted and Location:
Medical test Result (Fit/Unfit/Fit with Observation) : Fit Unfit Fit with observation
I am 18 years of age or older  STOP
No means STOP - do not commence work. - Site management before working
Which training certificate* do you Hold? None
I have been instructed on the above items
Certificates will be required for examination & photocopying

Operatives Name: Signature: Date: Trade:

Details Contact No:

Instructors Name: Signature:

 ASSA CONSTRUCTION

CHECKLIST FOR LABOUR CAMP

Project Site: Date:
Location of Labour Camp:
Frequency:
Sr. Satisfactory
Check Points Yes / No Remarks
No.
01 Does structural stability certificate of labour camp submitted?
02 Does the camp have clear access-egress?
03 Is unauthorized entry restricted?
04 Adequate security arrangement in labour camp
Are the floors, bathrooms, toilets, wash-basin areas free of slip-trip
05
& fall hazards?
Are separate toilets provided for men & women & marked in English,
06
Hindi & a local language?
07 Adequate illumination & ventilation in & around labour camp?
08 All electrical connections taken through RCCB / ELCB & are safe?
09 Is cooking facility safe & hygienic?
Adequate numbers of Fire Extinguishers & Fire Bucket provided at
10
proper locations and maintained?
11 Adequate number of waste bins provided & cleaned regularly?
12 Housekeeping proper in & around labour camp?
13 Sufficient numbers of toilets provided & cleaned regularly?
Potable drinking water provided & regular cleaning of water tanks
14
done?
15 Emergency Assembly point & emergency exit provided?
Drainage system proper & operational? No water accumulation in &
16
around camp?
17 Regular spraying of insecticides & fogging in the camp?
18 Is the camp stink-free?
19 Are the accommodation units (rooms) hygienic?
20 Washing & cleaning facilities provided?
Bathing areas are to be separate if families reside in the camp, these
21
washing & cleaning facilities also are to be maintained.
22 If families with small children are residing in the camp, provide
crèches facility & strictly control the movement in working area to
 ASSA CONSTRUCTION

avoid accidents.
Barricading in labour camp- Pits, holes, cutouts if any covered
23
properly?
24 Safety training provided?

Admin. Personnel Site Safety Representative

_______________________ ___________________________
(Name & Signature) (Name & Signature)
Date: Date:
 ASSA CONSTRUCTION

INCIDENT REPORT
Project:
East region India: Project No:
Type of Incident: Contractor:

What happened?

What caused it to happen?

When did it happen? (date and time): Where did it happen?

What would stop it happening again?

Was Property damaged? YES/NO If yes, what?

Was the environmental damaged? YES/NO If yes, what?

Any witnesses: NO/If yes, No Name :

Was anyone Injured (YES/NO):
Name of Injured Person? Age : Phone:
Home Address:
Was the injured person:  ASSA CONSTRCUTION employee  contract employee  Sub
contractor employee
 Member of the public  other. Clients Vendor

What was the injured person doing at the time of injury?

What was the injury and to what body part?

How was it treated on site? The IP was rushed to the site first aid center for treatment.

Who performed this? First Aider

Referral for Medical Advice: First-Aid room Own Doctor  Other? Nearby tie up hospital.

Date of Occurrence: Time:

Location:

Report Date: Reporter: Project Manager of :

Action Taken by whom and when: Immediate action taken by:
Name & Signature of Construction Manager as having received this report : N/A

FORM STATUS Copy to Sent Comment

Mandatory.  Reporter PM & SO Copy to ....... Y ........
 ASSA CONSTRUCTION

Optional (but with fills in Reviews HSSE head ................

intent on Yes Yes
file) . . . Prepared by

File . . . . . . . . . . . . . . . .

DIESEL GENERATOR SAFETY INSPECTION CHECKLIST

Project Name Date of Inspection

Contractor Name Month

S. DESCRIPTION COMPLIANCE COMMENTS

NO YES NO
01 The Condition of Diesel Generator is good

02 Safety guards to provide for all movable parts?

03 Are removed all flammable materials from D.G.

Room?
04 Is any oil leakage in D.G. Set?

05 Is well ventilation in D.G. room?

06 Is clear approach to D.G. room?

07 Are provided rain protected shelter?

08 Are displayed caution boards?

09 Sufficient number of fire extinguishers

provided.
10 Are provided fire buckets?

11 Are provided ear muff to operator?

12 Are pollution tested?

13 Is any gas storage near D.G. room?

14 Is any oil storage near D.G. room?

15 Is all power cables in good condition?

16 Is all power cables laid above 10” height?

17 Is provide suitable MCB in D.G. room?

18 Is provide earthing to D.G.set?

 ASSA CONSTRUCTION

Inspected By Reviewed By
Signature Signature

PORTABLE TOOLS (POWER OPERATED) AND EQUIPMENTS SAFETY INSPECTION

CHECKLIST

Project Name Date of Inspection

Contractor Name Machine’s Model / Type
Identification No. Type of Tool

Sl.No. DESCRIPTION Yes No Remarks

Are grinders, saws and similar equipment provided with
1 appropriate safety guards?
Are power tools used with the correct shield, guard, or
2 Attachment, recommended by the manufacturer?
Are portable circular saws equipped with guards above
and below the base shoe? Are circular saw guards
checked to assure they are not wedged up, thus leaving
3 the lower portion of the blade unguarded?
Are rotating or moving parts of equipment guarded to prevent
4 physical contact?
Are all cord-connected, electrically operated tools and
equipment effectively grounded or of the approved
5 double insulated type?
Are effective guards in place over belts, pulleys,
chains, sprockets, on equipment such as concrete
6 mixers, and air compressors?
Are portable fans provided with full guards or screens having
7 openings ½ inch or less?
Is hoisting equipment available and used for lifting
heavy objects, and are hoist ratings and characteristics
8 appropriate for the task?
Are ground-fault circuit interrupters provided on all
temporary electrical 15 and 20 ampere circuits, used
9 during periods of construction?
Are pneumatic and hydraulic hoses on power
operated tools checked regularly for
10 deterioration or damage?

Inspected By Reviewed By
Signature Signature
 ASSA CONSTRUCTION

SAFETY CHECKLIST FOR MOBILE SCAFFOLDING

Project Name Date of Inspection
Contractor Name Type of Scaffold
Location Scaffolding No.

Sl Description Observation Remarks

# Yes/No/ NA
1 Vertical members of the frames are secured by lateral
bracing

2 Bracing squares and aligns the frames

3 All brace connections are secured

4 The scaffold has the correct tube and clamp or frame for its
specific type
5 Casters are locked during use

6 Force is applied as close to the bottom as possible when

manually moving the scaffold
7 Casters are pinned into the frames and provided with
adjustment screws
8 Scaffold is stabilized to prevent tipping during movement

9 Employees are prohibited from riding on rolling towers when

they are being moved or moving them from the top of the
platform

Inspected By Reviewed By
Signature Signature
 ASSA CONSTRUCTION

VEHICLE SAFETY INSPECTION CHECKLIST

Project Name Date of Inspection
Contractor Name Vehicle Number
Location Type of Vehicle

S. NO DESCRIPTION COMPLIANCE COMMENTS

YES NO
01 Vehicle History
1. Is valid fitness certificate available?
2. Is valid insurance available?
3. Is registration certificate available with
driver?
02 License number of driver and validity

03 Is horn in working condition?

04 Is reverse horn in working condition?

05 Are all lights in working condition?

06 Are all indicators in working condition?

07 Condition of tyres pressure

08 Are provided the Door Locks?

09 Are provided the Seat belt?

10 Are lighting available in driver cabin?

11 Is Fire extinguisher available in cabin?

12 Is first aid kit available in cabin?

13 Are all drivers attended the safety induction

programme?.
 ASSA CONSTRUCTION

Inspected By Reviewed By
Signature Signature

Safe Work Method Statement Worksheet (Job Hazard Analysis)

Project Name: Project No.
Work Activity / Task: Contractor Name:
Date:` Prepared By:
Contractor In-charge: Signature:

Item Job Step Potential Hazards Safety Control Measures Responsibility

Commends:
Prepared By Reviewed & Approved By Explained to Site Signature
Vendor ASSA CONSTRCUTION Engineer
Project Manager Name &
Signature
Safety Officer Name &
 ASSA CONSTRUCTION

Signature
Date

FIRE EXTINGUISHER SAFETY INSPECTION CHECKLIST

Project Name Date of Inspection

Contractor Name Month

Obstruction Free
Servicing Labels

Pressure gauge

Missing / not in place

Seal (Broken?)

Accessibility
Hose \ Horn
Nozzle

Empty
Shell
Sl. Identificatio
No n No:

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
 ASSA CONSTRUCTION

Inspected By Reviewed By
Signature Signature

INFRACTION FORM

ASSA CONSTRCUTION CONTRACTOR HEALTH AND SAFETY

Sl. No………………… Date…………………

General information ( To be Completed by Safety officer )
Contractor Name :

Project Name :

On site contractor Representative / Supervisor / Safety

Location of Infraction :

Description of Infraction:

Observed By : Date : Time :

Status of Project : Project Stopped until correction

Project Continuing W/infraction

Corrective Actions Required by ( Date/time)

CORRECTIVE ACTION ( To be Completed by the Contractor )

Corrective Action :

Corrective Action Performed by :

Date / time :
Name : Signature :
Return to M/s ASSA CONSTRCUTION
CORRECTIVE ACTION FOLLOW UP ( To be completed by ASSA CONSTRCUTION)
 ASSA CONSTRUCTION

Received / Certified By : ASSA CONSTRCUTION

Date :

Remarks :