ATTACHMENT A Page 1 of 4

YANSAB PROJECT
Weekly Safety Assessment Report
The following is to be used as a guide by the team to perform the safety inspection.
Observations should be noted on the attached observation sheet. Upon completion
of the inspection each category should be rated as: from 10 high to 1 low.
Subtract 1 point for each deficiency/violation. 0 Lacking or N/A Not Applicable.
Deduct 10 points off total score for each life threatening/imminent danger.
Supervisor's Name: Date: Score Points %
Location: Safety Rep.: 0.00% Awarded
1 Housekeeping
1 Project work areas are clean and free of excess trash, debris 10
2 Walkways and passageways clear 10
3 Material or equipment properly stored 10
4 Electrical cords, hoses, welding leads, etc. elevated to prevent trip hazards 10
5 Scrap material free of protruding nails or other puncture hazards 10
6 Trash receptacles are provided for work areas and water kegs 10
7 Barricades, and/or rebar caps installed and maintained 10
8 Other;
POSSIBLE POINTS AWARDED 70 0 0%

2 Personal Protective Equipment

1 Hard hats worn and maintained as required 10
2 Hearing protection worn as required 10
3 Eye protection required and worn in a proper manner 10
4 Proper foot protection worn for job performed 10
5 Face shield or goggles worn as required 10
6 Other; respirators, gloves, chemical resistant garments 10
POSSIBLE POINTS AWARDED 60 0 0%

3 Fall Protection
1 Body harness required and worn in a proper manner 10
2 Lanyards are adequately secured to suitable anchorage 10
3 Perimeter guarding 10
4 Static lines, rat lines installed and capable of supporting 5,400 lbs. of force 10
5 Fall protection equipment is used only for fall protection 10
6 Fall protection maintained and has current inspection 10
POSSIBLE POINTS AWARDED 60 0 0%

4 Excavations
1 Sloped and shored properly 10
2 Access and egress provided every 25 ft. 10
3 Daily documented inspections conducted 10
POSSIBLE POINTS AWARDED 30 0 0%

5 Scaffolds and Ladders

1 Built per specification 10
2 Proper access and egress provided 10
3 Tagged correctly 10
4 Proper ladder for the job performed / properly secured 10
5 Proper angle and exceed the landing 3 ft. 10
POSSIBLE POINTS AWARDED 50 0 0%
YANSAB PROJECT
Safety Assessment Report (Page 2)
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6 Hoisting and Lifting Equipment Score See Points

1 Chainfalls, come-a-longs and chokers in good condition with current inspection 10
2 Softeners used as required 10
3 Proper rigging techniques used 10
POSSIBLE POINTS AWARDED 30 0 0%

7 Vehicles / Mobile Equipment

1 Lights, brakes, horns, alarms working properly 10
2 Seat belts provided and used 10
3 Properly maintained 10
4 Equipment used properly 10
5 Licenses or certifications as required 10
POSSIBLE POINTS AWARDED 50 0 0%

8 Tools and Equipment

1 Electrical cords - condition and current inspection 10
2 Tools are maintained in a safe condition 10
3 Tools are properly carried and stored 10
4 Pneumatic / hydraulic hose connections properly secured 10
5 Proper tools used for the job performed 10
6 Proper adjustment on work rest and wheels properly dressed on bench grinders 10
POSSIBLE POINTS AWARDED 60 0 0%

9 Fire Protection
1 Flammables stored properly 10
2 Oxygen and combustibles separated 10
3 Containers labeled as to content 10
4 Fire extinguishers properly located and inspected 10
5 Flash arrestors installed 10
6 Compressed gas cylinders properly maintained 10
7 Containment of hot work and welding screens as required 10
8 Regulator gauges properly attached and maintained 10
POSSIBLE POINTS AWARDED 80 0 0%

10 Safe Work Plan / Permits

1 Safe Work Plan and Applicable permits posted 10
2 Pre-talk-safety reviews (Toolbox Talks) 10
3 Procedures being followed i.e., Hazard assessment, confined space, lead, asbestos etc. 10
POSSIBLE POINTS AWARDED 30 0 0%
POINTS SCORED 520 0
ADJUSTED SCORE 0.00%
11 Signatures Required; Supervisor- _______________________
General Foreman- _______________________
Superintendent- _______________________
Owner.-

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YANSAB PROJECT

Safety Assessment Summary

The following is the rating classification established for the program;

95 to 100 Excellent 90 to 94 Good

85 to 89 Fair 70 to 84 Lacking

Supervisor's Name: Date: Score

Location: Safety Rep.: 0.00%

1 Housekeeping 0%

2 Personal Protective Equipment 0%

3 Fall Protection 0%

4 Excavations 0%

5 Scaffolds and Ladders 0%

6 Hoisting and Lifting Equipment 0%

7 Vehicles / Mobile Equipment 0%

8 Tools and Equipment 0%

9 Fire Protection 0%

10 Safe Work Plan / Permits 0%

OBSERVATION RESP. IND. CORRECTED

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The responsible individual for observations requiring corrective action shall sign off as
corrected and return this report within 24 hours of receipt. A status report shall be attached
for observations that are not corrected.

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